PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 03-10-050.
Title of Rule: Part 2 of 3, chapter 388-550 WAC, Hospital services, amending WAC 388-550-1400 Covered revenue codes for hospital services.
Purpose: To avoid federal penalties, the department is amending these rules to be HIPAA-compliant by October 16, 2003.
Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, and 74.08.090.
Statute Being Implemented: RCW 74.04.050, 74.04.057, and 74.08.090.
Summary: The department is amending the rules to comply with the requirements of the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191. Also, the rules are being revised to ensure the department's administrative code reflects current policy and practice.
Reasons Supporting Proposal: Complies with the HIPAA requirements and avoids federal penalties by amending rules to be HIPAA-compliant by October 16, 2003. Updates rule content to reflect current department policy.
Name of Agency Personnel Responsible for Drafting: Kathy Sayre, P.O. Box 45533, Olympia, WA 98504, (360) 725-1342; Implementation and Enforcement: Cynthia Smith, P.O. Box 45510, Olympia, WA 98504, (360) 725-1839.
Name of Proponent: Department of Social and Health Services, governmental.
Rule is necessary because of federal law, Public Law 104-191 (Health Insurance Portability and Accountability Act of 1996).
Explanation of Rule, its Purpose, and Anticipated Effects: The proposed rules meet HIPAA-specific standards that all states must meet in regards to electronic health information transactions and the privacy of client health information. In addition, the proposed rules update rule content and create a new section to update revenue code categories and subcategories and reporting requirements for inpatient and outpatient claims. Also, the proposed rules clarify that revenue code categories and subcategories are published in the UB-92 National Uniform Billing Data Element Specifications Manual and add language to state that MAA requires a hospital provider to report and bill hospital services under the appropriate revenue codes published in the UB-92 manual.
The purpose of the rules is to ensure department rules are HIPAA-compliant by October 16, 2003, and to adopt into permanent rule clarifying language to reflect current department policy and business practices.
The anticipated effects are: (1) The state will meet HIPAA-specific standards which all states are required to meet in regards to electronic health information transactions and the privacy of client health information. (2) MAA rules will be HIPAA-compliant by October 16, 2003, thereby avoiding federal penalties. (3) MAA's revenue code categories and subcategories and reporting requirements for inpatient and outpatient claims will be updated.
Proposal Changes the Following Existing Rules: The department is amending language to comply with HIPAA requirements. In addition, the department has added language to clarify that revenue code categories and subcategories are published in the UB-92 National Uniform Billing Data Element Specifications Manual. The new rules also add language regarding MAA reporting and billing requirements for hospital services under the appropriate revenue codes published in the UB-92 manual.
No small business economic impact statement has been prepared under chapter 19.85 RCW. Small businesses are not affected by these rule changes.
RCW 34.05.328 applies to this rule adoption. The rules meet the definition of a "significant legislative rule." The department has prepared a cost benefit analysis (CBA) memo regarding these rule changes. A copy of the memo can be obtained from Cynthia Smith, Division of Business and Finance, Medical Assistance Administration, Department of Social and Health Services, P.O. Box 45510, Olympia, WA 98504-5510, phone (360) 725-1839, e-mail smithch@dshs.wa.gov.
Hearing Location: Blake Office Park (behind Goodyear Courtesy Tire), 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on August 26, 2003, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by August 22, 2003, phone (360) 664-6094, TTY (360) 664-6178, e-mail fernaax@dshs.wa.gov.
Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, mail to P.O. Box 45850, Olympia, WA 98504-5850, deliver to 4500 10th Avenue S.E., Lacey, WA, fax (360) 664-6185, e-mail fernaax@dshs.wa.gov by 5:00 p.m., August 26, 2003.
Date of Intended Adoption: Not sooner than August 27, 2003.
July 17, 2003
Brian H. Lindgren, Manager
Rules and Policies Assistance Unit
3273.1(a) "Pharmacy," except that:
(i) Subcategories "take-home drugs," "experimental drugs," and "other pharmacy" are not covered; and
(ii) Subcategory "nonprescription" is covered for inpatients only;
(b) "Intravenous (IV) therapy," except subcategory "other IV therapy";
(c) "Medical/surgical supplies and devices," except for the following subcategories:
(i) "Take home supplies";
(ii) "Prosthetic devices";
(iii) "Oxygen - take home"; and
(iv) "Other supplies/devices."
(d) "Oncology," except subcategory "other oncology";
(e) "Respiratory services," except subcategory "other respiratory services";
(f) Subcategories "general classification" and "minor surgery" under the "operating room services" category;
(g) "Anesthesia," except subcategories "acupuncture" and "other anesthesia";
(h) "Blood storage and processing," except subcategory "other blood storage and processing";
(i) "Other imaging services," except subcategory "other image services";
(j) "Emergency room," except subcategory "other emergency room";
(k) "Pulmonary function," except subcategory "other pulmonary function";
(l) "Cardiology," except subcategory "other cardiology";
(m) "Magnetic resonance imaging (MRI)," except subcategory "other MRI";
(n) "Cast room," except subcategory "other cast room";
(o) "Recovery room," except subcategory "other recovery room";
(p) "Labor room/delivery," except for subcategories "circumcision" and "other labor room/delivery";
(q) "EKG/ECG (electrocardiogram)," except subcategory "other EKG/ECG";
(r) "EEG (electroencephalogram)," except subcategory "other EEG";
(s) "Gastrointestinal services," except subcategory "other gastroenteritises";
(t) "Treatment or observation room," except subcategory "other treatment room";
(u) "Lithotripsy," except subcategory "other lithotripsy"; and
(v) "Organ acquisition," except for subcategories "unknown donor" and "other organ."
(2) Except for certain services, such as inpatient hospice services covered by MAA pursuant to other rules, the department shall cover the following revenue code categories and/or subcategories for inpatient hospitalizations only:
(a) "Room and board - private, medical, or general," except subcategory "hospice";
(b) "Semi-private room and board" (two to four beds), except subcategory "hospice";
(c) "Nursery for newborns and premature babies";
(d) "Intensive care," except subcategory "post-ICU";
(e) "Coronary care," except subcategory "post-CCU";
(f) "Laboratory," except subcategory "renal patient (home)";
(g) "Laboratory pathological";
(h) "Radiology," both "diagnostic" and "therapeutic";
(i) "Nuclear medicine";
(j) "Physical therapy," "occupational therapy," and "speech-language therapy";
(k) "CT (computed tomographic) scans";
(l) "Operating room services," subcategories "organ transplant other than kidney" and "kidney transplant only";
(m) "Clinic," subcategory "chronic pain center" only;
(n) "Ambulance," subcategory "neonatal ambulance services (support crews)" only;
(o) "Other donor bank" category, except that subcategories "peripheral blood stem cell harvesting" and "reinfusion" are limited only to facilities approved by the medical assistance administration (MAA).
In addition to specifically excluded subcategories, the subcategory "other" in each category shall not be covered.
(3) Except for certain services, such as inpatient hospice services covered by MAA pursuant to other rules, the department shall cover the following revenue code categories for outpatient hospital services only:
(a) "Ambulatory surgical care";
(b) "Outpatient services";
(c) Subcategories "general classification" and "dental clinic," under "clinic";
(d) Subcategory "rural health clinic," under "free-standing clinic";
(e) "Drugs requiring specific identification," except covered only for certified kidney centers;
(f) "Hospice services";
(g) "Respite care";
(h) "Inpatient renal dialysis";
(i) "Hemodialysis - outpatient or home";
(j) "Peritoneal dialysis - outpatient or home";
(k) "Continuous ambulatory peritoneal dialysis - outpatient or home";
(l) "Continuous cycling peritoneal dialysis - outpatient or home";
(m) "Miscellaneous dialysis";
(n) Subcategories "education/training" and "weight loss," under the "other therapeutic services" category, except limited to facilities approved by MAA.
In addition to specifically excluded subcategories, the subcategory "other" in each category shall not be covered.
(4) The department shall cover the following revenue code categories and/or subcategories subject to the following specific limitations:
(a) The "private (deluxe)" and "room and board - ward" categories shall be reimbursed at the semi-private hospital room rates.
(b) All inpatient psychiatric services shall be subject to the policies and procedures of the mental health division, and reimbursed only to department-approved psychiatric facilities. See chapter 246-318 WAC. Inpatient psychiatric revenue codes include, but are not limited to:
(i) The subcategory "psychiatric" under all "room and board" categories;
(ii) The subcategory "psychiatric" under the "intensive care" category;
(iii) The "psychiatric/psychological treatments" category; and
(iv) The "psychiatric/psychological services" category.
(c) The department shall reimburse the subcategory "detoxification" under all room and board categories only to detoxification facilities approved by the division of alcohol and substance abuse.
(d) The subcategory "rehabilitation" under all "room and board" categories shall be reimbursed only to MAA-approved rehabilitation facilities.
(e) Only the subcategories "chemical-using pregnant women" and "administrative days" shall be covered in the "other room and board" category.
(f) Subcategory "nonprescription drugs" under the category "pharmacy" shall be covered for inpatient hospitalizations only. See WAC 388-550-1400 (1)(a)(ii). Certain exemptions apply for pregnant women as described in WAC 388-530-1150 (1)(d)(ii). For coverage of nonprescription drugs, see WAC 388-530-110 and 388-530-1150.
(g) The subcategories "renal patient (home)" and "nonroutine dialysis" under category "laboratory" shall be reimbursed in the outpatient setting only to Medicare-certified kidney centers.
(h) Subcategory "chronic pain center" under the "clinic" category shall be reimbursed only to MAA-approved chronic pain treatment facilities.
(i) Only the subcategory "neonatal ambulance services (support crews)" under the "ambulance" category shall be covered, and only for inpatient hospitalizations.
(j) The category "drugs requiring specific identification" shall be reimbursed only for outpatients and only to Medicare-approved kidney centers.
(k) Subcategories "education/training" and "weight loss," under the "other therapeutic service" category, shall be reimbursed only to MAA-approved facilities)) Subject to the limitations and restrictions listed, this section identifies covered and noncovered revenue code categories and subcategories for inpatient hospital services.
(1) The department covers the following revenue code categories and subcategories for inpatient hospital services when the hospital provider accurately bills:
(a) "Room & board - private," only subcategories "general classification," "medical/surgical/gyn," "OB," "pediatric," and "oncology";
(b) "Room & board - semi-private two bed," only subcategories "general classification," "medical/surgical/gyn," "OB," "pediatric," and "oncology";
(c) "Room & board - semi-private - three and four beds," only subcategories "general classification," "medical/surgical/gyn," "OB," "pediatric," and "oncology";
(d) "Room & board - private (deluxe)," only subcategories "general classification," "medical/surgical/gyn," "OB," "pediatric," and "oncology";
(e) "Nursery," only subcategories "general classification," "newborn - level I," "newborn - level II," "newborn - level III," and "newborn - level IV";
(f) "Intensive care," only subcategories "general classification,""surgical," "medical," "pediatric," "intermediate ICU," "burn care," and "trauma";
(g) "Coronary care," only subcategories "general classification,""myocardial infarction," "pulmonary care," and "intermediate CCU";
(h) "Pharmacy," only subcategories "general classification," "generic drugs," "nongeneric drugs," "drugs incident to other diagnostic services," "drugs incident to radiology," "nonprescription," and "IV solutions";
(i) "IV therapy," only subcategories "general classification," "infusion pump," "IV therapy/pharmacy services," "IV therapy/drug/supply delivery" and "IV therapy/supplies";
(j) "Medical/surgical supplies and devices," only subcategories"general classification," "nonsterile supply," "sterile supply," "pacemaker," "intraocular lens," and "other implant";
(k) "Oncology," only subcategory "general classification";
(l) "Laboratory," only subcategories "general classification," "chemistry," "immunology," "nonroutine dialysis," "hematology," "bacteriology & microbiology," and "urology";
(m) "Laboratory pathological," only subcategories "general classification," "cytology," "histology," and "biopsy";
(n) "Radiology - diagnostic," only subcategories "general classification," "angiocardiography," "arthrography," "arteriography," and "chest x-ray";
(o) "Radiology - therapeutic," only subcategories "general classification," "chemotherapy - injected," "chemotherapy - oral," "radiation therapy," and "chemotherapy - IV";
(p) "Nuclear medicine," only subcategories "general classification," "diagnostic," and "therapeutic";
(q) "CT Scan," only subcategories "general classification," "head scan,"and "body scan";
(r) "Operating room services," only subcategories "general classification" and "minor surgery";
(s) "Anesthesia," only subcategories "general classification," "anesthesia incident to radiology," and "anesthesia incident to other diagnostic services";
(t) "Blood and blood component administration, processing and storage," only subcategories "general classification" and "administration (e.g., transfusions)";
(u) "Other imaging services," only subcategories "general classification," "diagnostic mammography," "ultrasound," and "positron emission tomography";
(v) "Respiratory services," only subcategories "general classification,""inhalation services" and "hyper baric oxygen therapy";
(w) "Physical therapy," only subcategories "general classification," "visit charge," "hourly charge," "group rate," and "evaluation or re-evaluation";
(x) "Speech-language pathology," only subcategories "general classification," "visit charge," "hourly charge," "group rate," and "evaluation or re-evaluation";
(y) "Emergency room," only subcategories "general
classification" and "urgent care";
(z) "Pulmonary function," only subcategory "general classification";
(aa) "Cardiology," only subcategories "general classification," "cardiac cath lab," "stress test," and "echocardiology";
(bb) "Ambulatory surgical care," only subcategory "general classification";
(cc) "Outpatient services," only subcategory "general classification";
(dd) "Magnetic resonance technology (MRT)," only subcategories "general classification," "MRI - brain (including brainstem)," "MRI - spinal cord (including spine)," "MRI - other," "MRA - head and neck," and "MRA - lower extremities";
(ee) "Medical/surgical supplies - extension," only subcategories "supplies incident to radiology," "supplies incident to other diagnostic services," and "surgical dressings";
(ff) "Pharmacy-extension," only subcategories "single source drug," "multiple source drug," "restrictive prescription," "erythropoietin (EPO) less than ten thousand units," "erythropoietin (EPO) ten thousand or more units," "drugs requiring detailed coding," and "self-administrable drugs";
(gg) "Cast room," only subcategory "general classification";
(hh) "Recovery room," only subcategory "general classification";
(ii) "Labor room/delivery," only subcategory "general
classification," "labor," "delivery," and "birthing center";
(jj) "EKG/ECG (Electrocardiogram)," only subcategories "general classification," "holter monitor," and "telemetry";
(kk) "EEG (Electroencephalogram)," only subcategory "general classification";
(ll) "Gastro-intestinal services," only subcategory "general classification";
(mm) "Treatment/observation room," only subcategories "general classification," "treatment room," and "observation room";
(nn) "Lithotripsy," only subcategory "general classification";
(oo) "Inpatient renal dialysis," only subcategories "general classification," "inpatient hemodialysis," "inpatient peritoneal (non-CAPD)," "inpatient continuous ambulatory peritoneal dialysis (CAPD)," and "inpatient continuous cycling peritoneal dialysis (CCPD)";
(pp) "Acquisition of body components," only subcategories"general classification," "living donor," and "cadaver donor";
(qq) "Miscellaneous dialysis," only subcategory "ultra filtration," and
(rr) "Other diagnostic services," only subcategories "peripheral vascularlab," "electromyelogram," and "pregnancy test."
(2) The department covers the following revenue code subcategories for inpatient hospital services only when the hospital provider is approved by the department to provide the specific service(s):
(a) "All inclusive rate," only subcategory "all-inclusive room & board plus ancillary";
(b) "Room & board - private," only subcategory "psychiatric";
(c) "Room & board - semi-private two," only subcategories "psychiatric," "detoxification," "rehabilitation," and "other";
(d) "Room & board - semi-private three and four beds," only subcategories "psychiatric" and "detoxification";
(e) "Room & board - private (deluxe)," only subcategory "psychiatric";
(f) "Room & board - ward," only subcategories "general classification" and "detoxification";
(g) "Room & board - other," only subcategories "general classification" and "other";
(h) "Intensive care," only subcategory "psychiatric";
(i) "Coronary care," only subcategory "heart transplant";
(j) "Operating room services," only subcategories "organ transplant-other than kidney" and "kidney transplant";
(k) "Occupational therapy," only subcategories "general classification," "visit charge," "hourly charge," "group rate" and "evaluation or re-evaluation";
(l) "Clinic," only subcategory "chronic pain clinic";
(m) "Ambulance," only subcategory "neonatal ambulance services";
(n) "Psychiatric/psychological treatments," only subcategory "electroshock treatment"; and
(o) "Psychiatric/psychological services," only subcategory "rehabilitation."
(3) The department covers revenue code category "occupational therapy," subcategories "general classification, "visit charge, "hourly charge," "group rate," and "evaluation or re-evaluation" when:
(a) A client is in an acute PM&R facility;
(b) A client is age twenty or younger; or
(c) The diagnosis code is listed in the medical assistance administration's (MAA's) published billing instructions.
(4) The department does not cover the following revenue code categories and subcategories for inpatient hospital services:
(a) "All inclusive rate," subcategory "all-inclusive room and board";
(b) "Room & board - private" subcategories "hospice," "detoxification," "rehabilitation," and "other";
(c) "Room & board - semi-private two bed," subcategory "hospice";
(d) "Room & board - semi-private - three and four beds," subcategories "hospice," "rehabilitation," and "other";
(e) "Room & board - private (deluxe)," subcategories "hospice," "rehabilitation," and "other";
(f) "Room & board - ward," subcategories "medical/surgical/gyn," "OB," "pediatric" "hospice," "oncology," "rehabilitation," and "other";
(g) "Room & board - other," subcategories "sterile environment," and "self care";
(h) "Nursery," subcategory "other nursery";
(i) "Leave of absence";
(j) "Subacute Care";
(k) "Intensive care," subcategory "other intensive care";
(l) "Coronary care," subcategory "other coronary care";
(m) "Special charges";
(n) "Incremental nursing charge rate";
(o) "All inclusive ancillary";
(p) "Pharmacy," subcategories "take home drugs," "experimental drugs," and "other pharmacy";
(q) "IV therapy," subcategory "other IV therapy";
(r) "Medical/surgical supplies and devices," subcategories "take home supplies," "prosthetic/orthotics devices," "oxygen -take home," and "other supplies/devices";
(s) "Oncology," subcategory "other oncology";
(t) "Durable medical equipment (other than renal)";
(u) "Laboratory," subcategories "renal patient (home)," and "other laboratory";
(v) "Laboratory pathological," subcategory "other laboratory - pathological";
(w) "Radiology - diagnostic," subcategory "other radiology - diagnostic";
(x) "Radiology - therapeutic," subcategory "other radiology - therapeutic";
(y) "Nuclear medicine," subcategory "other nuclear medicine";
(z) "CT Scan," subcategory "other CT scan";
(aa) "Operating room services," subcategory "other operating room services";
(bb) "Anesthesia," subcategories "acupuncture," and "other anesthesia";
(cc) "Blood";
(dd) "Blood and blood component administration, processing and storage," subcategory "other processing and storage";
(ee) "Other imaging services," subcategories "screening mammography," and "other imaging services";
(ff) "Respiratory services," subcategory "other respiratory services";
(gg) "Physical therapy," subcategory "other physical therapy";
(hh) "Occupational therapy," subcategory "other occupational therapy";
(ii) "Speech-language pathology," subcategory "other speech-language pathology";
(jj) "Emergency room," subcategories "EMTALA emergency medical screening services," "ER beyond EMTALA screening," and "other emergency room";
(kk) "Pulmonary function," subcategory "other pulmonary function";
(ll) "Audiology";
(mm) "Cardiology," subcategory "other cardiology";
(nn) "Ambulatory surgical care," subcategory "other ambulatory surgical care";
(oo) "Outpatient services," subcategory "other outpatient service";
(pp) "Clinic," subcategories "general classification," "dental clinic," "psychiatric clinic," "OB-gyn clinic," "pediatric clinic," "urgent care clinic," "family practice clinic," and "other clinic";
(qq) "Free-standing clinic";
(rr) "Osteopathic services";
(ss) "Ambulance," subcategories "general classification," "supplies," "medical transport," "heart mobile," "oxygen," "air ambulance," "pharmacy," "telephone transmission EKG," and "other ambulance";
(tt) "Skilled nursing";
(uu) "Medical social services";
(vv) "Home health - home health aide";
(ww) "Home health - other visits";
(xx) "Home health - units of service";
(yy) "Home health - oxygen";
(zz) "Magnetic resonance technology (MRT)," subcategories "MRA-other" and "other MRT";
(aaa) "Medical" "medical/surgical supplies - extension," subcategory "FDA investigational devices";
(bbb) "Home IV therapy services";
(ccc) "Hospice services";
(ddd) "Respite care";
(eee) "Outpatient residence charges";
(fff) "Trauma response";
(ggg) "Cast room," subcategory "other cast room";
(hhh) "Recovery room," subcategory "other recovery room";
(iii) "Labor room/delivery," subcategories "circumcision" and "other labor room/delivery";
(jjj) "EKG/ECG (Electrocardiogram)," subcategory "other EKG/ECG";
(kkk) "EEG (Electroencephalogram)," subcategory "other EEG";
(lll) "Gastro-intestinal services," subcategory "other gastro-intestinal";
(mmm) "Treatment/observation room," subcategory "other treatment/observation room";
(nnn) "Preventive care services";
(ooo) "Telemedicine";
(ppp) "Lithotripsy," subcategory "other lithotripsy";
(qqq) "Inpatient renal dialysis," subcategory "other inpatient dialysis";
(rrr) "Acquisition of body components," subcategories "unknown donor," "unsuccessful organ search - donor bank charges," and "other donor";
(sss) "Hemodialysis - outpatient or home";
(ttt) "Peritoneal dialysis - outpatient or home";
(uuu) "Continuous ambulatory peritoneal dialysis (CAPD) - outpatient or home";
(vvv) "Continuous cycling peritoneal dialysis (CCPD) - outpatient or home";
(www) "Miscellaneous dialysis," subcategories "general classification," "home dialysis aid visit," and "other miscellaneous dialysis";
(xxx) "Psychiatric/psychological treatments," subcategories "general classification," "milieu therapy," "play therapy," "activity therapy," and "other psychiatric/psychological treatment";
(yyy) "Psychiatric/psychological services," subcategories "general classification," "partial hospitalization - less intensive," "partial hospitalization - intensive," "individual therapy," "group therapy," "family therapy," "bio feedback," "testing," and "other psychiatric/psychological service";
(zzz) "Other diagnostic services," subcategories "general classification," "pap smear," "allergy test," and "other diagnostic service";
(aaaa) "Medical rehabilitation day program";
(bbbb) "Other therapeutic services";
(cccc) "Professional fees";
(dddd) "Patient convenience items"; and
(eeee) Revenue code categories and subcategories that are not identified in this section.
.
[Statutory Authority: RCW 74.08.090. 01-02-075, § 388-550-1400, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-1400, filed 12/18/97, effective 1/18/98.]
Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.