Physician-Related Services/ Health Care Professional Services Provider Guide January 1, 2015 Physician-Related Services/Health Care Professional Services About this guide* This publication takes effect January 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 effective 1/1/2015 from the In accordance with WAC 182- Health Technology Clinical Committee 501-0055, the agency reviews (HTCC) the recommendations of HTCC and decides whether to adopt the recommendations Other surgical policies Clarified that an assistant at major surgery Clarify reimbursement for is paid at 20% of the surgical procedure’s modifier AS maximum allowable fee. Outpatient cardiac Added CPT code 93797 and HCPCS Policy update rehabilitation G0423 to list of billable codes for outpatient cardiac rehabilitation. Removed requirement for the client to have continuous cardiac monitoring during exercise Defined phase II of cardiac rehabilitation Advanced Added coverage for counseling and care Coverage update directives/POLST planning services for end of life treatment when conducted by a licensed health care provider Telephone services Added criteria for coverage of telephone Policy update services when used by a physician to report episodes of care initiated by an established patient Screening exams – Removed limitation of one every 11 to 12 Policy update Cancer screens months for HCPCS code G0101 Proton beam radiation Changed limitation of coverage HTCC Final Findings and therapy Decision for Proton Beam Therapy * This publication is a billing instruction. Physician-Related Services/Health Care Professional Services Subject Change Reason for Change Surgery – Smoking Added a Smoking Cessation section under Patients undergoing cervical Cessation (Spine Surgery. Nicotine use is a strong fusions and repeat fusions for Surgery) contraindication to spine surgeries. radiculopathy are required to abstain from nicotine for 4 weeks before surgery Cardiovascular system Added coverage and criteria HTCC Final Findings and – Carotid artery Decision for Carotid Artery stenting Stenting Cervical spinal fusion Added coverage and criteria Align policy with Labor & arthrodesis Industries’ Medical Treatment Guidelines (which comply with HTCC Final Findings and Decision) Cervical surgery for Clarified coverage and criteria Added limitation of coverage radiculopathy and criteria to provider guide. Not new myelopathy policy. Stereotactic radiation Added coverage and criteria HTCC Final Findings and surgery & Stereotactic Decision for Stereotactic body radiation therapy radiation surgery and stereotactic body radiation therapy Modifiers (59, XE, XS, Clarification for use of modifier 59. Added CMS developed these XP, and XU) information regarding new CMS modifiers modifiers to provider greater XE, XS, XP, and XU. Added the new reporting specificity in modifiers in several places along with situations where modifier 59 modifier 59. was previously reported and may be used in lieu of modifier 59 whenever possible Facet neurotomy Medical necessity review is conducted To align with Labor & through Qualis Health. Qualis Health will Industries MTG (eff use the Washington State’s Labor & 10/1/2014) (which complies Industries (L&I) Medical Treatment with the HTCC Final Findings Guidelines (MTG) with a few exceptions and Decision for Facet Neurotomy) Implantable infusion Struck CPT codes 62318 and 62319 from Codes were listed in error pumps or implantable list of payable codes drug delivery system (IDDS) Vaccines/Toxoids Added reminder that the E/M code 99211 Clarification cannot be billed with a vaccine or the vaccine administration code Primary Care Discontinuing the increased reimbursement The rate increase was Physicians (PCP) Rate rate for E/M services and vaccine authorized by the WA State Increase administration provided by attested PCPs Legislature for 1/1/2013 through 12/31/2014 ARNP Rate Increase Discontinuing the increased reimbursement The rate increase was rate for E/M services and vaccine authorized by the WA State administration provided by eligible Legislature for 7/1/2013 independent ARNPs through 12/31/2014 Physician-Related Services/Health Care Professional Services Subject Change Reason for Change Billing for transgender Billing for a transgender client and A secondary diagnosis is clients reporting change in gender required on claims to process correctly What dental services Clarified that medical providers means Clarification are billable by primary physicians, ARNPs, and PAs care medical providers? Maternity care and Added clarification in the header for Clarification for billing delivery - Billing with modifier GB and UA modifiers What foot care services Added an additional bullet: Policy change does the agency pay “Treatment of diabetic foot ulcers with for? Theraskin when prior authorization is obtained.” Hyperbaric oxygen Replaced deleted HCPCS code C1300 with Deleted /replaced code therapy HCPCS code G0277 Transient elastography Added coverage and expedited prior Coverage update authorization criteria for transient elastography only for determining if qualifying criteria measures are met for immune modulators and anti-viral medication treatment of chronic Hepatitis C virus infection Psychiatry – Clozaril Deleted HCPCS code M0064. Physicians, HCPCS code M0064 deleted case management psychiatrists, and ARNPs must bill for Clozaril case management using the applicable E/M code for drug monitoring. Expedited Prior Discontinued use of EPA #250 Billers must use EPA #241 or Authorization Codes For EPA #241 and #242, if EPA criteria is #242 not met, providers must request prior authorization Fee Schedule change Unbundling CPT codes 61781, 61782, CPT codes 61781, 61782, only 61783 61783 were previously bundled. The agency is unbundling these codes. Fee Schedule change CMS continually updates CPT. Check the CPT Book Updates only agency’s program-specific fee schedule, effective January 1, 2015, for possible code additions and deletions. 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 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. 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