Date of Adoption: September 5, 2003.

     Purpose: To enure department rules are HIPAA-compliant (federal Health Insurance Portability and Accountability Act, P.L. 104-191) by October 16, 2003, and to adopt into permanent rule clarifying language to reflect current department policy and business practices.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-550-1300 and 388-550-6000.

     Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, and 74.08.090.

     Other Authority: Public Law 104-191.

      Adopted under notice filed as WSR 03-15-130 on July 22, 2003.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 1, Amended 2, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 2, Repealed 0.
     Effective Date of Rule: Thirty-one days after filing.

September 5, 2003

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     (2))) Revenue code categories and subcategories listed in this chapter ((shall be as listed in the state of Washington's UB-92 procedure manual, implemented October 1, 1993, which was patterned after the national uniform billing data element specifications adopted by the national uniform billing committee)) are published in the UB-92 National Uniform Billing Data Element Specifications Manual.

     (2) The medical assistance administration (MAA) requires a hospital provider to report and bill all hospital services provided to medical assistance clients using the appropriate revenue codes published in the manual referenced in subsection (1) of this section.

[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, § 388-550-1300, filed 12/18/97, effective 1/18/98.]

     (a) "IV therapy," only subcategory "infusion pump";

     (b) "Medical/surgical supplies and devices," only subcategory "prosthetic/orthotic devices";

     (c) "Laboratory";

     (d) "Laboratory pathological";

     (e) "Radiology - diagnostic";

     (f) "Radiology - therapeutic";

     (g) "Nuclear medicine";

     (h) "CT Scan";

     (i) "Operating room services," only subcategories "general classification" and "minor surgery";

     (j) "Blood and blood component administration, processing and storage," only subcategory "administration (e.g., transfusions)";

     (k) "Other imaging services";

     (l) "Respiratory services";

     (m) "Physical therapy";

     (n) "Occupational therapy";

     (o) "Speech - language pathology";

     (p) "Emergency room," only subcategories "general classification" and "urgent care";

     (q) "Pulmonary function";

     (r) "Audiology";

     (s) "Cardiology";

     (t) "Ambulatory surgical care";

     (u) "Outpatient services";

     (v) "Clinic," only subcategories "general classification," "dental clinic," and "other clinic";

     (w) "Magnetic Resonance Technology (MRT)";

     (x) "Medical/surgical supplies - extension";

     (y) "Pharmacy - extension";

     (z) "Labor room/delivery," only subcategories "delivery" and "birthing center";

     (aa) "EKG/ECG (electrocardiogram)";

     (bb) "EEG (electroencephalogram)";

     (cc) "Gastro-intestinal services";

     (dd) "Treatment/observation room";

     (ee) "Lithotripsy";

     (ff) "Acquisition of body components," only subcategories "living donor" and "cadaver donor";

     (gg) "Hemodialysis - outpatient or home," only subcategory "general classification";

     (hh) "Peritoneal dialysis - outpatient or home," only subcategory "general classification";

     (ii) "Continuous ambulatory peritoneal dialysis (CAPD) -outpatient or home," only subcategory "general classification";

     (jj) "Continuous cycling peritoneal dialysis (CCPD) -outpatient or home," only subcategory "general classification";

     (kk) "Miscellaneous dialysis," only subcategories "general classification" and "ultrafiltration";

     (ll) "Psychiatric/psychological treatments," only subcategory "electroshock therapy";

     (mm) "Other diagnostic services";

     (nn) "Other therapeutic services," only subcategory "other therapeutic service"; and

     (oo) Other revenue code categories and subcategories identified and published by the department.

     (2) For an outpatient claim line requiring a CPT or HCPCS code(s), the department denies payment if the required code is not reported on the line.

[]

     (4))) The medical assistance administration (MAA) pays outpatient hospital providers for providing covered outpatient hospital services to medical assistance clients using the maximum allowable fee schedule and/or the hospital outpatient rate.

     (1) Maximum allowable fee schedule:

     (a) MAA uses the maximum allowable fee schedule to pay for services listed in the outpatient hospital fee schedule and published in MAA's billing instructions.

     (b) Outpatient hospital services are included in the outpatient hospital fee schedule when:

     (i) A technical component has been established in the Medicare Fee Schedule Data Base (MFSDB); or

     (ii) MAA specifically identifies certain services for payment using the maximum allowable fee schedule.

     (c) Outpatient hospital services paid using MAA's maximum allowable fee schedule include:

     (i) Laboratory services;

     (ii) Imaging services;

     (iii) EKG/ECG/EEG and other diagnostics;

     (iv) Physical therapy;

     (v) Occupational therapy;

     (vi) Speech/language therapy;

     (vii) Synagis;

     (viii) Sleep studies; and

     (ix) Other hospital services as identified and published by the department.

     (d) MAA's payment for covered services included in the outpatient hospital fee schedule is the lesser of:

     (i) The hospital's billed amount; or

     (ii) MAA's maximum allowable.

     (e) Certain services or supplies listed in the outpatient hospital fee schedule are identified and designated by MAA to be paid by acquisition cost or by report. See subsection (7) of this section for MAA's requirement for submitting invoices.

     (2) Outpatient rate:

     (a) MAA uses the outpatient rate to pay hospitals for covered services reported on a hospital claim that are not listed in the outpatient hospital fee schedule.

     (b) The outpatient rate is a hospital-specific rate that uses the hospital's ratio of costs-to-charges (RCC) rate as its base. MAA's rate-setting method for an outpatient rate is described in WAC 388-500-4500.

     (3) The department considers hospital stays of twenty-four hours or less outpatient short stays and uses the outpatient payment ((method to reimburse)) methods in subsections (1) and (2) of this section to pay a hospital for these ((stays)) services. However, when an outpatient short stay involves one of the following situations, the department uses inpatient payment methods to ((reimburse)) pay a hospital for covered services:

     (a) Death of a client;

     (b) Obstetrical delivery;

     (c) Initial care of a newborn; or

     (d) Transfer of a client to another acute care hospital.

     (((5) Under WAC 246-976-935, MAA may:

     (a) Enhance payments for trauma care provided to a client eligible under the medically indigent MI) program or a Title XIX Medicaid program when the trauma:

     (i) Qualifies under the trauma program; and

     (ii) Care is provided in a nongovernmental hospital designated by the department of health (DOH) as a trauma services center.

     (b) Provide an annual grant for trauma services to:

     (i) A governmental hospital certified by DOH as a trauma services center; and

     (ii) An MAA-approved critical access hospital (CAH).

     (6))) (4) The department uses the outpatient payment ((method to reimburse)) methods in subsections (1) and (2) of this section to pay for covered inpatient hospital services provided within twenty-four hours of a client's inpatient admission that are not related to the admission. Inpatient hospital services provided within twenty-four hours of a client's inpatient admission that are related to the admission are paid according to WAC 388-550-2900(12).

     (((7))) (5) For a client enrolled in an MAA-contracted ((Healthy Options)) managed care plan, the plan is responsible to ((reimburse)) pay a hospital provider for hospital services that the plan covers. MAA ((reimburses)) pays for a service not covered by the managed care plan only when:

     (a) The service is included in the scope of coverage under the client's medical assistance program;

     (b) The service is medically necessary as defined in WAC 388-550-1050; and

     (c) The provider has a current core provider agreement with MAA and meets applicable MAA program requirements in other published WACs.

     (((8))) (6) The department does not ((reimburse)) pay for:

     (a) Room and ancillary services charges beyond the twenty-four hour period for outpatient short stays; or

     (b) Emergency room, labor room, observation room, and other room charges in combination when billing periods for theses charges overlap.

     (((9))) (7) In order to be paid for covered outpatient hospital services listed in the outpatient hospital fee schedule as a paid at acquisition cost or by report, MAA requires the hospital provider to submit an invoice for billed amounts of five hundred or more.

     (8) In order to be ((reimbursed)) paid for covered outpatient hospital services, hospitals must bill MAA according to the conditions of payment under WAC 388-502-0100, time limits under WAC 388-502-0150, and other applicable published issuances. In addition, MAA requires hospitals to bill outpatient claims using the line item date of service and the appropriate revenue codes, ((CPT)) admit and discharge hour, Current Procedural Terminology (CPT) codes, Healthcare Common Procedural Coding System (HCPSCS) codes, and modifiers listed in MAA's published outpatient hospital fee schedule. A hospital's bill to the department must show the admitting, principal, and secondary diagnoses and include the attending physician's name and MAA-assigned provider number.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. 02-21-019, § 388-550-6000, filed 10/8/02, effective 11/8/02. Statutory Authority: RCW 74.09.090, 42 U.S.C. 1395x(v), 42 C.F.R. 447.271 and 42 C.F.R. 11303. 99-14-028, § 388-550-6000, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 42 USC 1395 x(v), 42 CFR 447.271, 447.11303, and 447.2652. 99-06-046, § 388-550-6000, filed 2/26/99, effective 3/29/99. 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, § 388-550-6000, 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.

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