WSR 03-19-046

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed September 10, 2003, 2:36 p.m. ]

Date of Adoption: September 5, 2003.

Purpose: To ensure 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 388-550-1500.

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 03-15-132 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Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 1, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.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

September 5, 2003

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3274.1
AMENDATORY SECTION(Amending WSR 98-01-124, filed 12/18/97, effective 1/18/98)

WAC 388-550-1500   Covered and noncovered revenue ((codes)) code categories and subcategories for outpatient hospital services.   (1) ((Revenue code subcategories titled "other" shall not be covered by the medical assistance administration (MAA), unless otherwise specified.

(2) The department shall not cover the following revenue code categories in either an inpatient or outpatient setting:

(a) "All-inclusive rate";

(b) "Other room and board," except as indicated in WAC 388-550-1400 (4)(e);

(c) "Leave of absence";

(d) "Not assigned" (all such categories);

(e) "Special charges";

(f) "Incremental nursing charge rate";

(g) "All-inclusive ancillary";

(h) "Pharmacy" subcategories for "take home" and "experimental drugs";

(i) "Durable medical equipment (other than renal)";

(j) "Blood" (and blood products);

(k) "Audiology";

(l) "Clinic," except as specified in WAC 388-550-1400 (3)(c);

(m) "Free-standing clinic," except as specified in WAC 388-550-1400 (3)(d);

(n) "Osteopathic services";

(o) "Ambulance," except as specified in WAC 388-550-1400 (4)(i);

(p) "Skilled nursing";

(q) "Medical social services";

(r) "Home health aide (home health)" and "other visits (home health)";

(s) "Units of service (home health)";

(t) "Oxygen (home health)";

(u) "Medicare/surgical supplies";

(v) "Home IV therapy services";

(w) "Preventive care services";

(x) "Other diagnostic services";

(y) "Professional fees" (all such categories); and

(z) "Patient convenience items."

(3) The department shall not cover the following subcategories in the "other therapeutic service" category:

(a) "General classification";

(b) "Recreational therapy";

(c) "Cardiac rehabilitation";

(d) "Drug rehabilitation," except under the chemically-using pregnant (CUP) women program;

(e) "Alcohol rehabilitation," except under the CUP program; and

(f) "Air fluidized support beds."

(4) The department shall not cover the following subcategories under the "free-standing clinic" category:

(a) "General classification";

(b) "Rural health - home";

(c) "Family practice"; and

(d) "Other clinic.")) The department covers the following revenue code categories and subcategories for outpatient hospital services when the hospital provider accurately bills (see subsection (2) of this section for revenue code subcategories covered only when the department approves the hospital provider to provide the specific service(s)):

(a) "Pharmacy," only subcategories "general classification," "generic drugs," "nongeneric drugs," "drugs incident to other diagnostic services," "drugs incident to radiology," "nonprescription," and "IV solutions";

(b) "IV therapy," only subcategories "general classification," "infusion pump," "IV therapy/pharmacy services," "IV therapy/drug/supply delivery," and "IV therapy/supplies";

(c) "Medical/surgical supplies and devices," only subcategories "general classification," "nonsterile supply," "sterile supply," "pacemaker," "intraocular lens," and "other implant";

(d) "Oncology," only subcategory "general classification";

(e) "Laboratory," only subcategories "general classification," "chemistry," "immunology," "renal patient (home)," "nonroutine dialysis," "hematology," "bacteriology and microbiology," and "urology";

(f) "Laboratory pathological," only subcategories "general classification," "cytology," "histology," and "biopsy";

(g) "Radiology - diagnostic," only subcategories "general classification," "angiocardiography," "arthrography," "arteriography," and "chest x-ray";

(h) "Radiology - therapeutic," only subcategories "general classification," "chemotherapy - injected," "chemotherapy - oral," "radiation therapy," and "chemotherapy - IV";

(i) "Nuclear medicine," only subcategories "general classification," "diagnostic," and "therapeutic";

(j) "CT Scan," only subcategories "general classification," "head scan," and "body scan";

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

(l) "Anesthesia," only subcategories "general classification," "anesthesia incident to radiology," and "anesthesia incident to other diagnostic services";

(m) "Blood and blood component administration, processing and storage," only subcategories "general classification" and "administration (e.g., transfusions)";

(n) "Other imaging," only subcategories "general classification," "diagnostic mammography," "ultrasound," "screening mammography," and "positron emission tomography";

(o) "Respiratory services," only subcategories "general classification," "inhalation services," and "hyper baric oxygen therapy";

(p) "Physical therapy," only subcategories "general classification," "visit charge," "hourly charge," "group rate," and "evaluation or re-evaluation";

(q) "Occupational therapy," only subcategories "general classification," "visit charge," "hourly charge," "group rate," and "evaluation or re-evaluation";

(r) "Speech-language pathology," only subcategories "general classification," "visit charge," "hourly charge," "group rate," and "evaluation or re-evaluation";

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

(t) "Pulmonary function," only subcategory "general classification";

(u) "Audiology," only subcategories "general classification," "diagnostic," and "treatment";

(v) "Cardiology," only subcategories "general classification," "cardiac cath lab," "stress test," and "echocardiology";

(w) "Ambulatory surgical care," only subcategory "general classification";

(x) "Outpatient services," only subcategory "general classification";

(y) "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";

(z) "Medical/surgical supplies - extension," only subcategories "supplies incident to radiology," "supplies incident to other diagnostic services," and "surgical dressings";

(aa) "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";

(bb) "Cast room," only subcategory "general classification";

(cc) "Recovery room," only subcategory "general classification";

(dd) "Labor room/delivery," only subcategories "general classification," "labor," "delivery," and "birthing center";

(ee) "EKG/ECG (Electrocardiogram)," only subcategories "general classification," "holter monitor," and "telemetry";

(ff) "EEG (Electroencephalogram)," only subcategory "general classification";

(gg) "Gastro-intestinal services," only subcategory "general classification";

(hh) "Treatment/observation room," only subcategories "general classification," "treatment room," and "observation room";

(ii) "Lithotripsy," only subcategory "general classification";

(jj) "Acquisition of body components," only subcategories "general classification," "living donor," and "cadaver donor";

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

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

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

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

(oo) "Miscellaneous dialysis," only subcategories "general classification," and "ultra filtration";

(pp) "Psychiatric/psychological treatments," only subcategory "electroshock treatment"; and

(qq) "Other diagnostic services," only subcategories "peripheral vascular lab," "electromyelogram," "pap smear," "allergy test," and "pregnancy test."

(2) The department covers the following revenue code subcategories only when the outpatient hospital provider is approved by the department to provide the specific service(s):

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

(b) "Other therapeutic services - extension," subcategories "education/training" and "other therapeutic service."

(3) The department does not cover the following revenue code categories and subcategories for outpatient hospital services:

(a) "All inclusive rate";

(b) "Room & board - private";

(c) "Room & board - semi-private two bed";

(d) "Room & board - semi-private three and four beds";

(e) "Room & board - private (deluxe)";

(f) "Room & board - ward";

(g) "Room & board - other";

(h) "Nursery";

(i) "Leave of absence";

(j) "Subacute care";

(k) "Intensive care";

(l) "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/orthotic devices," "oxygen - take home," and "other supplies/devices";

(s) "Oncology," subcategory "other oncology";

(t) "Durable medical equipment (other than renal)";

(u) "Laboratory," subcategory "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," subcategories "organ transplant - other than kidney," "kidney transplant," and "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," subcategory "other imaging service";

(ff) "Respiratory services," subcategory "other respiratory services";

(gg) "Physical therapy services," subcategory "other physical therapy";

(hh) "Occupational therapy services," 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," subcategory "other 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 "chronic pain center," "psychiatric clinic," "OB-GYN clinic," "pediatric clinic," "urgent care clinic," and "family practice clinic";

(qq) "Free-standing clinic";

(rr) "Osteopathic services";

(ss) "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/surgical supplies - extension," only subcategory "FDA investigational devices";

(bbb) "Home IV therapy services";

(ccc) "Hospice services";

(ddd) "Respite care";

(eee) "Outpatient special 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";

(rrr) "Acquisition of body components," subcategories "unknown donor," "unsuccessful organ search - donor bank charges," and "other donor";

(sss) "Hemodialysis - outpatient or home," subcategories "hemodialysis/composite or other rate," "home supplies," "home equipment," "maintenance one hundred percent," "support services," and "other outpatient hemodialysis";

(ttt) "Peritoneal dialysis - outpatient or home," subcategories "peritoneal/composite or other rate," "home supplies," "home equipment," "maintenance one hundred percent" "support services," and "other outpatient peritoneal dialysis";

(uuu) "Continuous ambulatory peritoneal dialysis (CAPD) - outpatient or home," subcategories "CAPD/composite or other rate," "home supplies," "home equipment," "maintenance one hundred percent" "support services," and "other outpatient CAPD";

(vvv) "Continuous cycling peritoneal dialysis (CCPD) - outpatient or home," subcategories "CCPD/composite or other rate," "home supplies," "home equipment," "maintenance one hundred percent, "support services," and "other outpatient CCPD";

(www) "Miscellaneous dialysis," subcategories "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";

(zzz) "Other diagnostic services," subcategories "general classification" and "other diagnostic services";

(aaaa) "Medical rehabilitation day program";

(bbbb) "Other therapeutic services - extension," subcategories "general classification," "recreational therapy," "cardiac rehabilitation," "drug rehabilitation," "alcohol rehabilitation," "complex medical equipment - routine," "complex medical equipment - ancillary," "athletic training," and "kinesiotherapy";

(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, 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, 388-550-1500, filed 12/18/97, effective 1/18/98.]

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