PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 96-07-045.
Title of Rule: New chapter 388-531 WAC, Physician-related services; and repealing WAC 388-86-011 Advanced registered nurse practitioners, 388-86-055 Laboratory services, 388-86-095 Physician services, 388-86-09601 Podiatric services, 388-86-110 X-ray services, 388-87-0075 Payment -- Laboratory services, and 388-87-095 Payment -- Physician services.
Purpose: The department is establishing a new chapter for rules pertaining to physician-related services. To avoid duplication, related rules in chapters 388-86 and 388-87 WAC are proposed for repeal.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.520.
Statute Being Implemented: RCW 74.08.090, 74.09.520.
Summary: The department is establishing a new chapter for rules pertaining to physician-related services. To avoid duplication, related rules in chapters 388-86 and 388-87 WAC are proposed for repeal.
Reasons Supporting Proposal: To consolidate physician-related services rules in one chapter. To add payment methodology to various physician-related service rules. To comply with the Governor's Executive Order 97-02.
Name of Agency Personnel Responsible for Drafting: Ann Myers, DPS/RIP, P.O. Box 45533, Olympia, WA 98504, (360) 725-1345; Implementation and Enforcement: Dave Cundiff M.D., P.O. Box 45500, Olympia, WA 98504, (360) 725-1500.
Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.
Rule is not necessitated by federal law, federal or state court decision.
Explanation of Rule, its Purpose, and Anticipated Effects: The proposed rule will consolidate physician-related services rules into one chapter. It also puts payment methodology into rule. As new and existing rules are consolidated into the new chapter, they have been reviewed and written to meet the clear-language guidelines in the Governor's Executive Order 97-02.
The purpose of this action is to move physician-related services into one chapter, and to state those rules in clear, understandable language. This contributes to better understanding and easier usage by both department staff and providers.
The anticipated effects are to make the rules easier to find and to understand.
Proposal Changes the Following Existing Rules: The proposal repeals rules listed above and restates those policies in the new chapter.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rules and concludes that, since the rules reflect no change in current policy, no new costs will [be] imposed on the small businesses affected by them.
RCW 34.05.328 applies to this rule adoption. The department has analyzed the proposed rules and determined that they meet the definition of a "significant legislative rule." An analysis of the probable costs and benefits is available from the person listed above.
Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on August 8, 2000, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Fred Swenson by July 28, 2000, phone (360) 664-6097, TTY (360) 664-6178, e-mail swensfh@dshs.wa.gov.
Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by August 8, 2000.
Date of Intended Adoption: August 9, 2000.
June 1, 2000
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit
2678.12PHYSICIAN-RELATED SERVICES
The following definitions and abbreviations and those found in WAC 388-500-0005, apply to this chapter. Defined words and phrases are bolded the first time they are used in the text.
"Acquisition cost" means the cost of an item excluding shipping, handling, and any applicable taxes.
"Acute care" means care provided for clients who are not medically stable. These clients require frequent monitoring by a health care professional in order to maintain their health status (WAC 248-27-015).
"Acute physical medicine and rehabilitation (PM&R)" means a comprehensive inpatient and rehabilitative program coordinated by a multidisciplinary team at an MAA-approved rehabilitation facility. The program provides twenty-four hour specialized nursing services and an intense level of specialized therapy (speech, physical, and occupational) for a diagnostic category for which the client shows significant potential for functional improvement (see WAC 388-550-2501).
"Add-on procedure(s)" means secondary procedure(s) that are performed in addition to another procedure.
"Admitting diagnosis" means the medical condition responsible for a hospital admission, as defined by ICD-9-M diagnostic code.
"Advanced registered nurse practitioner (ARNP)" means a registered nurse prepared in a formal educational program to assume an expanded health services provider role in accordance with WAC 246-840-300 and 246-840-305.
"Aging and adult services administration (AASA)" means the administration that administers directly or contracts for long-term care services, including but not limited to nursing facility care and home and community services. See WAC 388-15-202.
"Allowed charges" means the maximum amount for any procedure that is allowed by MAA.
"Anesthesia technical advisory group (ATAG)" means an advisory group representing anesthesiologists who are affected by the implementation of the anesthesiology fee schedule.
"Base anesthesia units (BAU)" means a number of anesthesia units assigned to a surgical procedure that includes the usual pre-operative, intra-operative, and post-operative visits. This includes the administration of fluids and/or blood incident to the anesthesia care, and interpretation of noninvasive monitoring by the anesthesiologist.
"Bundled services" means services integral to the major procedure that are included in the fee for the major procedure. Bundled services are not reimbursed separately.
"Bundled supplies" means supplies which are considered to be included in the practice expense RVU of the medical or surgical service of which they are an integral part.
"By report (BR)" means a method of reimbursement in which MAA determines the amount it will pay for a service that is not included in MAA's published fee schedules. MAA may request the provider to submit a "report" describing the nature, extent, time, effort, and/or equipment necessary to deliver the service.
"Call" means a face-to-face encounter between the client and the provider resulting in the provision of services to the client.
"Cast material maximum allowable fee" means a reimbursement amount based on the average cost among suppliers for one roll of cast material.
"Certified registered nurse anesthetist (CRNA)" means an advanced registered nurse practitioner (ARNP) with formal training in anesthesia who meets all state and national criteria for certification. The American Association of Nurse Anesthetists specifies the National Certification and scope of practice.
"Children's health insurance plan (CHIP)," see chapter 388-542 WAC.
"Clinical Laboratory Improvement Amendment (CLIA)" means regulations from the U.S. Department of Health and Human Services that require all laboratory testing sites to have either a CLIA registration or a CLIA certificate of waiver in order to legally perform testing anywhere in the U.S.
"Conversion factors" means dollar amounts MAA uses to calculate the maximum allowable fee for physician-related services.
"Covered service" means a service that is within the scope of the eligible client's medical care program, and listed in specific fee-for-service billing instructions.
"CPT," see "current procedural terminology."
"Critical care services" means physician services for the care of critically ill or injured clients. A critical illness or injury acutely impairs one or more vital organ systems such that the client's survival is jeopardized. Critical care is given in a critical care area, such as the coronary care unit, intensive care unit, respiratory care unit, or the emergency care facility.
"Current procedural terminology (CPT)" means a systematic listing of descriptive terms and identifying codes for reporting medical services, procedures, and interventions performed by physicians and other practitioners who provide physician-related services. CPT is copyrighted and published annually by the American Medical Association (AMA).
"Diagnosis code" means a set of numeric or alphanumeric characters assigned by the ICD-9-CM, or successor document, as a shorthand symbol to represent the nature of a disease.
"Emergency medical condition(s)" means a medical condition(s) that manifests itself by acute symptoms of sufficient severity so that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
"Emergency services" means medical services required by and provided to a patient experiencing an emergency medical condition.
"Estimated acquisition cost (EAC)" means the department's best estimate of the price providers generally and currently pay for drugs and supplies.
"Evaluation and management (E&M) codes" means procedure codes which categorize physician services by type of service, place of service, and patient status.
"Expedited prior authorization" means the process of obtaining authorization that must be used for selected services, in which providers use a set of numeric codes to indicate to MAA which acceptable indications, conditions, diagnoses, and/or criteria are applicable to a particular request for services.
"Experimental" means a term to describe a procedure, or course of treatment, which lacks sufficient scientific evidence of safety and effectiveness. See WAC 388-531-0500. A service is not "experimental" if the service:
(1) Is generally accepted by the medical profession as effective and appropriate; and
(2) Has been approved by the FDA or other requisite government body.
"Fee-for-service" means the general payment method MAA uses to reimburse providers for covered medical services provided to clients for whom those services are not covered under MAA's healthy options program or children's health insurance program (CHIP) programs.
"Flat fee" means the maximum allowable fee established by MAA for a service or item that does not have a relative value unit (RVU) or has an RVU that is not appropriate.
"Geographic practice cost index (GPCI)" as defined by Medicare, means a Medicare adjustment factor that includes local geographic area estimates of how hard the provider has to work (work effort), what the practice expenses are, and what malpractice costs are. The GPCI reflects one-fourth the difference between the area average and the national average.
"Global surgery reimbursement," see WAC 388-531-1700.
"HCPCS Level II" means a coding system established by the HCFA to define services and procedures not included in CPT.
"Health Care Financing Administration (HCFA)" means the agency within the federal Department of Health and Human Services (DHHS) with oversight responsibility for the Medicare and Medicaid programs.
"Health Care Financing Administration Common Procedure Coding System (HCPCS)" means the name used for the Health Care Financing Administration codes made up of CPT and HCPCS level II codes.
"Health care team" means a group of health care providers involved in the care of a client.
"Hospice" means a medically directed, interdisciplinary program of palliative services which is provided under arrangement with a Title XVIII Washington licensed and certified Washington state hospice for terminally ill clients and the clients' families.
"ICD-9-CM," see "International Classification of Diseases, 9th Revision, Clinical Modification".
"Informed consent" means that an individual consents to a procedure after the provider who obtained a properly completed consent form has done all of the following:
(1) Disclosed and discussed the client's diagnosis; and
(2) Offered the client an opportunity to ask questions about the procedure and to request information in writing; and
(3) Given the client a copy of the consent form; and
(4) Communicated effectively using any language interpretation or special communication device necessary per 42 C.F.R. Chapter IV 441.257; and
(5) Given the client oral information about all of the following:
(a) The client's right to not obtain the procedure, including potential risks, benefits, and the consequences of not obtaining the procedure; and
(b) Alternatives to the procedure including potential risks, benefits, and consequences; and
(c) The procedure itself, including potential risks, benefits, and consequences.
"Inpatient hospital admission" means an acute hospital stay for longer then twenty-four hours when the medical care record shows the need for inpatient care beyond twenty-four hours. All admissions are considered inpatient hospital admissions, and are paid as such, regardless of the length of stay, in the following circumstances:
(1) The death of a client;
(2) Obstetrical delivery;
(3) Initial care of a newborn; or
(4) Transfer to another acute care facility.
"International Classification of diseases, 9th Revision, Clinical Modification (ICD-9-CM)" means the systematic listing that transforms verbal descriptions of diseases, injuries, conditions, and procedures into numerical or alphanumerical designations (coding).
"Investigational" means a term to describe a procedure, or course of treatment, which lacks sufficient scientific evidence of benefit for a particular condition. A service is "investigational" if the service:
(1) Is generally accepted by the medical professional as effective and appropriate for the condition in question; or
(2) Is supported by a preponderance of objective scientific evidence, in which the risks and benefits are examined, demonstrating the proposed service to be of greater overall benefit to the client in the particular circumstance than another, generally available service.
"Life support" means mechanical systems, such as ventilators or heart-lung respirators, which are used to supplement or take the place of the normal autonomic functions of a living person.
"Limitation extension" means a process for requesting and approving reimbursement for covered services whose proposed quantity, frequency, or intensity exceeds that which MAA routinely reimburses. Limitation extensions require prior authorization.
"Maximum allowable fee" means the maximum dollar amount that MAA will reimburse a provider for specific services, supplies, and equipment.
"Medically necessary," see WAC 388-500-0005.
"Medicare Physician Fee Schedule Data Base (MPFSDB)" means the official HCFA publication of the Medicare policies and RVUs for the RBRVS reimbursement program.
"Medicare Program Fee Schedule for Physician Services (MPFSPS)" means the official HCFA publication of the Medicare fees for physician services.
"Medicare Clinical Diagnostic Laboratory Fee Schedule" means the fee schedule used by Medicare to reimburse for clinical diagnostic laboratory procedures in the state of Washington.
"Mentally incompetent" means a client who has been declared mentally incompetent by a federal, state, or local court.
"Modifier" means a two-digit alphabetic and/or numeric identifier that is added to the procedure code to indicate the type of service performed. The modifier provides the means by which the reporting physician can describe or indicate that a performed service or procedure has been altered by some specific circumstance but not changed in its definition or code. The modifier can affect payment or be used for information only. Modifiers are listed in fee schedules.
"Outpatient" means a client who is receiving medical services in other than an inpatient hospital setting.
"Peer-reviewed medical literature" means medical literature published in professional journals that submit articles for review by experts who are not part of the editorial staff. It does not include publications or supplements to publications primarily intended as marketing material for pharmaceutical, medical supplies, medical devices, health service providers, or insurance carriers.
"Physician care plan" means a written plan of medically necessary treatment that is established by and periodically reviewed and signed by a physician. The plan describes the medically necessary services to be provided by a home health agency, a hospice agency, or a nursing facility.
"Physician standby" means physician attendance without direct face-to-face client contact and which does not involve provision of care or services.
"Physician's current procedural terminology," see "CPT, current procedural terminology."
"PM&R," see acute physical medicine and rehabilitation.
"Podiatric service" means the diagnosis and medical, surgical, mechanical, manipulative, and electrical treatments of ailments of the foot and ankle.
"Pound indicator (#)" means a symbol (#) indicating a CPT procedure code listed in MAA fee schedules that is not routinely covered.
"Preventive" means medical practices that include counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of appropriate laboratory and diagnostic procedures intended to help a client avoid or reduce the risk or incidence of illness or injury.
"Prior authorization" means a process by which clients or providers must request and receive MAA approval for certain medical services, equipment, or supplies, based on medical necessity, before the services are provided to clients, as a precondition for provider reimbursement. Expedited prior authorization and limitation extension are forms of prior authorization.
"Professional component" means the part of a procedure or service that relies on the provider's professional skill or training, or the part of that reimbursement that recognizes the provider's cognitive skill.
"Prognosis" means the probable outcome of a client's illness, including the likelihood of improvement or deterioration in the severity of the illness, the likelihood for recurrence, and the client's probable life span as a result of the illness.
"Prolonged services" means face-to-face client services furnished by a provider, either in the inpatient or outpatient setting, which involve time beyond what is usual for such services. The time counted toward payment for prolonged E&M services includes only face-to-face contact between the provider and the client, even if the service was not continuous.
"Provider," see WAC 388-500-0005.
"Radioallergosorbent test" or "RAST" means a blood test for specific allergies.
"RBRVS," see resource based relative value scale.
"RVU," see relative value unit.
"Reimbursement" means payment to a provider or other MAA-approved entity who bills according to the provisions in WAC 388-502-0100.
"Reimbursement steering committee (RSC)" means an interagency work group that establishes and maintains RBRVS physician fee schedules and other payment and purchasing systems utilized by the health care authority, MAA, and department of labor and industries.
"Relative value guide (RVG)" means a system used by the American Society of Anesthesiologists for determining base anesthesia units (BAUS).
"Relative value unit (RVU)" means a unit which is based on the resources required to perform an individual service or intervention.
"Resource based relative value scale (RBRVS)" means a scale that measures the relative value of a medical service or intervention, based on the amount of physician resources involved.
"RBRVS RVU" means a measure of the resources required to perform an individual service or intervention. It is set by Medicare based on three components - physician work, practice cost, and malpractice expense. Practice cost varies depending on the place of service.
"RSC RVU" means a unit established by the RSC for a procedure that does not have an established RBRVS RVU or has an RBRVS RVU deemed by the RSC as not appropriate for the service.
"Stat laboratory charges" means charges by a laboratory for performing tests immediately. "Stat" is an abbreviation for the Latin word "statim," meaning immediately.
"State unique procedure codes" means procedure codes established by the RSC to define services or procedures not contained in CPT or HCPCS level II.
"Sterile tray" means a tray containing instruments and supplies needed for certain surgical procedures normally done in an office setting. For reimbursement purposes, tray components are considered by HCFA to be nonroutine and reimbursed separately.
"Technical advisory group (TAG)" means an advisory group with representatives from professional organizations whose members are affected by implementation of RBRVS physician fee schedules and other payment and purchasing systems utilized by the health care authority, MAA, and department of labor and industries.
"Technical component" means the part of a procedure or service that relates to the equipment set-up and technician's time, or the part of the procedure and service reimbursement that recognizes the equipment cost and technician time.
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(1) The medical assistance administration (MAA) covers medical services, equipment, and supplies when they are both:
(a) Within the scope of an eligible client's medical care program. Refer to chapter 388-529 WAC; and
(b) Medically necessary as defined in 388-500-0005.
(2) MAA evaluates a request for any service that is listed as noncovered in WAC 388-531-0150 under the provisions of WAC 388-501-0165 which relate to noncovered services.
(3) MAA evaluates a request for a service that is in a covered category, but has been determined to be experimental or investigational under WAC 388-531-0550, under the provisions of WAC 388-501-0165 which related to medical necessity.
(4) MAA evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions when medically necessary, under the standards for covered services in WAC 388-501-0165.
(5) MAA covers the following physician-related services, subject to the conditions in subsection (1) and (2) of this section:
(a) Allergen immunotherapy services;
(b) Anesthesia services;
(c) Dialysis and end stage renal disease services (refer to chapter 388-540 WAC);
(d) Emergency physician services;
(e) ENT (ear, nose, and throat) related services;
(f) Early and periodic screening, diagnosis, and treatment (EPSDT) services (refer to WAC 388-534-0100);
(g) Gender dysphoria surgery and related procedures, treatment, prosthetics, or supplies when recommended after a multidisciplinary evaluation including at least urology, endocrinology, and psychiatry;
(h) Family planning services (refer to chapter 388-532 WAC);
(i) Hospital inpatient services (refer to chapter 388-550 WAC);
(j) Maternity care, delivery, and newborn care services (refer to chapter 388-533 WAC);
(k) Office visits;
(l) Ophthalmology care services;
(m) Osteopathic treatment services;
(n) Pathology and laboratory services;
(o) Physiatry and other rehabilitation services (refer to chapter 388-550 WAC);
(p) Podiatry services;
(q) Primary care services;
(r) Psychiatric services, provided by a psychiatrist;
(s) Pulmonary and respiratory services;
(t) Radiology services;
(u) Surgical services;
(v) Surgery to correct defects from birth, illness, or trauma, or for mastectomy reconstruction; and
(w) Other outpatient physician services.
(6) MAA covers physical examinations for MAA clients only when the physical examination is one or more of the following:
(a) A screening exam covered by the EPSDT program (see WAC 388-534-0100);
(b) An annual exam for clients of the division of developmental disabilities; or
(c) A screening pap smear, mammogram, or prostate exam.
(7) By providing covered services to a client eligible for a medical care program, a provider who has signed an agreement with MAA accepts MAA's rules and fees as outlined in the agreement, which includes federal and state law and regulations, billing instructions, and MAA issuances.
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(1) Except as provided in WAC 388-531-0100 and subsection (2) of this section, MAA does not cover the following:
(a) Acupuncture, massage, or massage therapy;
(b) Any service specifically excluded by statute;
(c) Care, testing, or treatment of infertility, frigidity, or impotency. This includes procedures for donor ovum, sperm, womb, and reversal of vasectomy or tubal ligation;
(d) Cosmetic treatment or surgery, except for medically necessary reconstructive surgery to correct defects attributable to trauma, birth defect, or illness;
(e) Experimental or investigational services, procedures, treatments, devices, drugs, or application of associated services, except when the individual factors of an individual client's condition justify a determination of medical necessity under WAC 388-501-0165;
(f) Hair transplantation;
(g) Marital counseling or sex therapy;
(h) More costly services when MAA determines that less costly, equally effective services are available;
(i) Orthoptic eye training therapy;
(j) Payment for body parts, including organs, tissues, bones and blood, except as allowed in WAC 388-531-1750;
(k) Physician-supplied medication, except those drugs administered by the physician in the physician's office;
(l) Physical examinations or routine checkups, except as provided in WAC 388-531-0100;
(m) Routine foot care. This does not include clients who have a medical condition that affects the feet, such as diabetes or arteriosclerosis obliterans. Routine foot care includes, but is not limited to:
(i) Treatment of mycotic disease;
(ii) Removal of warts, corns, or calluses;
(iii) Trimming of nails and other hygiene care; or
(iv) Treatment of flat feet;
(n) Except as provided in WAC 388-531-1600, weight reduction and control services, procedures, treatments, devices, drugs, products, or the application of associated services.
(o) Nonmedical equipment; and
(p) Nonemergent admissions and associated services to out-of-state hospitals or noncontracted hospitals in contract areas.
(2) MAA covers excluded services listed in (1) of this subsection if those services are mandated under and provided to a client who is eligible for one of the following:
(a) The EPSDT program;
(b) A Medicaid program for qualified Medicare beneficiaries (QMBs); or
(c) A waiver program.
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(1) MAA requires prior authorization for certain services. Prior authorization includes expedited prior authorization (EPA) and limitation extension (LE). See WAC 388-501-0165.
(2) The EPA process is designed to eliminate the need for telephone prior authorization for selected admissions and procedures.
(a) The provider must create an authorization number using the process explained in MAA's physician-related billing instructions.
(b) Upon request, the provider must provide supporting clinical documentation to MAA showing how the authorization number was created.
(c) Selected nonemergent admissions to contract hospitals require EPA. These are identified in MAA billing instructions.
(d) Procedures requiring expedited prior authorization include, but are not limited to, the following:
(i) Bladder repair;
(ii) Hysterectomy for clients age forty-five and younger, except with a diagnosis of cancer(s) of the female reproductive system;
(iii) Outpatient magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA);
(iv) Reduction mammoplasties/mastectomy for geynecomastia; and
(v) Strabismus surgery for clients eighteen years of age and older.
(3) MAA evaluates new technologies under the procedures in WAC 388-531-0550. These require prior authorization.
(4) Prior authorization is required for the following:
(a) abdominoplasty;
(b) All inpatient hospital stays for acute physical medicine and rehabilitation (PM&R);
(c) Cochlear implants, which also:
(i) For coverage, must be performed in an ambulatory surgery center (ASC) or an inpatient or outpatient hospital facility; and
(ii) For reimbursement, must have the invoice attached to the claim;
(d) Diagnosis and treatment of eating disorders for clients twenty-one years of age and older;
(e) Osteopathic manipulative therapy in excess of MAA/s published limits;
(f) Panniculectomy;
(g) Surgical procedures related to weight loss or reduction; and
(h) Vagus nerve stimulator insertion, which also:
(i) For coverage, must be performed in an inpatient or outpatient hospital facility; and
(ii) For reimbursement, must have the invoice attached to the claim.
(5) MAA may require a second opinion and/or consultation before authorizing any elective surgical procedure.
(6) Children six year of age and younger do not require authorization for hospitalization.
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(1) The following enrolled providers are eligible to provide and bill for physician-related medical services which they provide to eligible clients:
(a) Advanced registered nurse practitioners (ARNP);
(b) Federally qualified health centers (FQHCs);
(c) Health departments;
(d) Hospitals currently licensed by the department of health;
(e) Independent (outside) laboratories CLIA certified to perform tests. See WAC 388-531-0800;
(f) Licensed radiology facilities;
(g) Medicare-certified ambulatory surgery centers;
(h) Medicare-certified rural health clinics;
(i) Providers who have a signed agreement with MAA to provide screening services to eligible persons in the EPSDT program;
(j) Registered nurse first assistants (RNFA); and
(k) Persons currently licensed by the state of Washington department of health to practice any of the following:
(i) Dentistry (refer to chapter 388-535 WAC);
(ii) Medicine and osteopathy;
(iii) Nursing;
(iv) Optometry, for vision-related services; or
(v) Podiatry, for podiatric services.
(2) MAA does not reimburse for services performed by any of the following practitioners:
(a) Acupuncturists;
(b) Christian Science practitioners or theological healers;
(c) Counselors;
(d) Herbalists;
(e) Homeopaths;
(f) Massage therapists as licensed by the Washington state department of health;
(g) Naturopaths;
(h) Sanipractors;
(i) Those who have a master's degree in social work (MSW), except those employed by an FQHC;
(j) Any other licensed or unlicensed practitioners not otherwise specifically provided for in WAC 388-87-005; or
(k) Any other licensed practitioners providing services which the practitioner is not:
(i) Licensed to provide; and
(ii) Trained to provide.
(3) MAA reimburses practitioners listed in subsection (2) of this section for physician-related services if those services are mandated by, and provided to, clients who are eligible for one of the following:
(a) The EPSDT program;
(b) A Medicaid program for qualified Medicare beneficiaries (QMB); or
(c) A waiver program.
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MAA bases coverage of anesthesia services on Medicare policies and the following rules:
(1) MAA reimburses providers for covered anesthesia services performed by:
(a) Anesthesiologists;
(b) Certified registered nurse anesthetists (CRNAs);
(c) Oral surgeons with a special agreement with MAA to provide anesthesia services; and
(d) Other providers who have a special agreement with MAA to provide anesthesia services.
(2) MAA covers and reimburses anesthesia services for children and noncooperative clients in those situations where the medically necessary procedure cannot be performed if the client is not anesthetized. A statement of the client-specific reasons why the procedure could not be performed without specific anesthesia services must be kept in the client's medical record. Examples of such procedures include:
(a) Computerized tomography (CT);
(b) Dental procedures;
(c) Electroconvulsive therapy; and
(d) Magnetic resonance imaging (MRI).
(3) MAA covers anesthesia services provided for any of the following:
(a) Dental restorations and/or extractions:
(b) Maternity per subsection (9) of this section. See WAC 388-531-1550 for information about sterilization/hysterectomy anesthesia;
(c) Pain management per subsection (5) of this section;
(d) Radiological services as listed in WAC 388-531-1450; and
(e) Surgical procedures.
(4) For each client, the anesthesiologist provider must do all of the following:
(a) Perform a pre-anesthetic examination and evaluation;
(b) Prescribe the anesthesia plan;
(c) Personally participate in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence;
(d) Ensure that any procedures in the anesthesia plan that the provider does not perform, are performed by a qualified individual as defined in the program operating instructions;
(e) At frequent intervals, monitor the course of anesthesia during administration;
(f) Remain physically present and available for immediate diagnosis and treatment of emergencies; and
(g) Provide indicated post anesthesia care.
(5) MAA does not allow the anaesthesiologist provider to:
(a) Direct more than four anesthesia services concurrently; and
(b) Perform any other services while directing the single or concurrent services, other than attending to medical emergencies and other limited services as allowed by Medicare instructions.
(6) MAA requires the anesthesiologist provider to document in the client's medical record that the medical direction requirements were met.
(7) General anesthesia:
(a) When a provider performs multiple operative procedures for the same client at the same time, MAA reimburses the base anesthesia units (BAU) for the major procedure only.
(b) MAA does not reimburse the attending surgeon for anesthesia services.
(c) When more than one anesthesia provider is present on a case, MAA reimburses as follows:
(i) The supervisory anesthesiologist and certified registered nurse anesthetist (CRNA) each receive fifty percent of the allowed amount.
(ii) For anesthesia provided by a team, MAA limits reimbursement to one hundred percent of the total allowed reimbursement for the service.
(8) Pain management:
(a) MAA pays CRNAs or anesthesiologists for pain management services.
(b) MAA allows two postoperative or pain management epidurals per client, per hospital stay plus the two associated E&M fees for pain management.
(9) Maternity anesthesia:
(a) To determine total time for obstetric epidural anesthesia during normal labor and delivery and c-sections, time begins with insertion and ends with removal for a maximum of six hours. "Delivery" includes labor for single or multiple births, and/or cesarean section delivery.
(b) MAA does not apply the six-hour limit for anesthesia to procedures performed as a result of post-delivery complications.
(c) See WAC 388-531-1550 for information on anesthesia services during a delivery with sterilization.
(d) See chapter 388-533 WAC for more information about maternity-related services.
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(1) MAA reimburses anesthesia services on the basis of base anesthesia units (BAU) plus time.
(2) MAA calculates payment for anesthesia by adding the BAU to the time units and multiplying that sum by the conversion factor. The formula used in the calculation is: (BAU x fifteen) + time) x (conversion factor divided by fifteen)= reimbursement.
(3) MAA obtains BAU values from the relative value guide (RVG), and updates them annually. MAA and/or the anesthesia technical advisory group (ATAG) members establish the base units for procedures for which anesthesia is appropriate but do not have BAUs established by RVSP and are not defined as add-on.
(4) MAA determines a budget neutral anesthesia conversion factor by:
(a) Determining the BAUs, time units, and expenditures for a base period for the provided procedure. Then,
(b) Adding the latest BAU RVSP to the time units for the base period to obtain an estimate of the new time unit for the procedure. Then,
(c) Multiplying the time units obtained in (b) of this subsection for the new period by a conversion factor to obtain estimated expenditures. Then,
(d) Comparing the expenditures obtained in (c) of this subsection with base period expenditure levels obtained in (a) of this subsection. Then,
(e) Adjusting the dollar amount for the anesthesia conversion factor and the projected time units at the new BAUs equals the allocated amount determined in (a) of this subsection.
(5) MAA calculates anesthesia time units as follows:
(a) One minute equals one unit.
(b) The total time is calculated to the next whole minute.
(c) Anesthesia time begins when the anesthesiologist, surgeon, or CRNA begins physically preparing the client for the induction of anesthesia; this must take place in the operating room or its equivalent. When there is a break in continuous anesthesia care, blocks of time may be added together as long as there is continuous monitoring. Examples of this include, but are not limited to, the following:
(i) The time a client spends in an anesthesia induction room; or
(ii) The time a client spends under the care of an operating room nurse during a surgical procedure.
(d) Anesthesia time ends when the anesthesiologist, surgeon, or CRNA is no longer in constant attendance (i.e., when the client can be safely placed under post-operative supervision).
(6) MAA changes anesthesia conversion factors if the legislature grants a vendor rate increase, or other increase, and if the effective date of that increase is not the same as MAA's annual update.
(7) If the legislatively authorized vendor rate increase or other increase becomes effective at the same time as MAA's annual update, MAA applies the increase after calculating the budget-neutral conversion factor.
(8) When more than one surgical procedure is performed at the same operative session, MAA uses the BAU of the major procedure to determine anesthesia allowed charges. MAA reimburses add-on procedures as defined by CPT only for the time spent on the add-on procedure that is in addition to the time spent on the major procedure.
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Clients may be responsible to reimburse the provider, as described under WAC 388-501-0100, for services that are not covered under the client's medical care program. Clients whose care is provided under CHIP may be responsible for copayments as outlined in chapter 388-542 WAC. Also, see WAC 388-502-0160, Billing the client.
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(1) MAA reimburses the following physicians for critical care services:
(a) The attending physician who assumes responsibility for the care of a client during a life-threatening episode;
(b) More than one physician if the services provided involve multiple organ systems; or
(c) Only one physician for services provided in the emergency room.
(2) MAA reimburses preoperative and postoperative critical care in addition to a global surgical package when all the following apply:
(a) The client is critically ill and the physician is engaged in work directly related to the individual client's care, whether that time is spent at the immediate beside or elsewhere on the floor;
(b) The critical injury or illness acutely impairs one or more vital organ systems such that the client's survival is jeopardized;
(c) The critical care is unrelated to the specific anatomic injury or general surgical procedure performed; and
(d) The provider uses any necessary, appropriate modifier when billing MAA.
(3) MAA limits payment for critical care services to a maximum of three hours per day, per client.
(4) MAA does not pay separately for certain services performed during a critical care period when the services are provided on a per hour basis. These services include, but are not limited to, the following:
(a) Analysis of information data stored in computers (e.g., ECG, blood pressure, hematologic data);
(b) Blood draw for a specimen;
(c) Blood gases;
(d) Cardiac output measurement;
(e) Chest X-rays;
(f) Gastric intubation;
(g) Pulse oximetry;
(h) Temporary transcutaneous pacing;
(i) Vascular access procedures; and
(j) Ventilator management.
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(1) MAA reimburses for E&M services provided in the hospital emergency department to clients who arrive for immediate medical attention.
(2) MAA reimburses emergency physician services only when provided by physicians assigned to the hospital emergency department or the physicians on call to cover the hospital emergency department.
(3) MAA pays a provider who is called back to the emergency room at a different time on the same day to attend a return visit the same client. When this results in multiple claims on the same day, the time of each encounter must be clearly indicated on the claim.
(4) MAA does not pay emergency room physicians for hospital admission charges or additional service charges.
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(1) When MAA makes a determination as to whether a proposed service is experimental or investigational, MAA follows the procedures in this section. The policies and procedures and any criteria for making decisions are available upon request.
(2) In making the determination, whether a service is experimental and investigational and, therefore, not a covered service, MAA considers the following:
(a) Evidence in peer-reviewed medical literature, as defined in WAC 388-531-0050, and pre-clinical and clinical data reported to the National Institute of Health and/or the National Cancer Institute, concerning the probability of the service maintaining or significantly improving the enrollee's length or quality of life, or ability to function, and whether the benefits of the service or treatment are outweighed by the risks of death or serious complications;
(b) Whether evidence indicates the service or treatment is likely to be an beneficial as existing conventional treatment alternatives;
(c) Any relevant, specific aspects of the condition;
(d) Whether the service or treatment is generally used for the condition in the state of Washington;
(e) Whether the service or treatment is under continuing scientific testing and research;
(f) Whether the service or treatment shows a demonstrable benefit for the condition;
(g) Whether the service or treatment is safe and efficacious;
(h) Whether the service or treatment will result in greater benefits for the condition than another generally available service; and
(i) If approval is required by a regulating agency, such as the Food and Drug Administration, whether such approval has been given before the date of service.
(3) MAA applies consistently across clients, the criteria to determine whether a service is experimental. A service or treatment that is not experimental for one client with a particular medical condition is not determined to be experimental for another enrollee with the same medical condition and similar health status.
(4) MAA does not determine a service or treatment to be experimental or investigational solely because it is under clinical investigation when there is sufficient evidence in peer-reviewed medical literature to draw conclusions, and the evidence indicates the service or treatment will probably be of greater overall benefit to the client in question and to others similarly situated, than another generally available service.
(5) All determinations that a proposed service or treatment is "experimental" or "investigation" are subject to the review and approval of a physician who is:
(a) Licensed under chapter 18.57 RCW or an osteopath licensed under chapter 18.71 RCW;
(b) Designated by MAA's medical director to issue such approvals; and
(c) Available to consult with the client's treating physici8an by telephone.
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MAA covers one pre- and one post-HIV/AIDS counseling/testing session per client each time the client is tested for HIV/AIDS.
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MAA covers the following services without prior authorization when provided in MAA-approved centers of excellence. MAA issues periodic publications listing centers of excellence. These services include the following:
(1) All transplant procedures specified in WAC 388-550-1900;
(2) Chronic pain management services, including outpatient evaluation and inpatient treatment, as described under WAC 388-550-2400. See also WAC 388-531-0700;
(3) Sleep studies including but not limited to polysomnograms for clients one year of age and older. MAA allows sleep studies only in outpatient hospital settings as described under WAC 388-550-6350. See also WAC 388-531-1500;
(4) Diabetes education, in a DOH-approved facility, per WAC 388-550-6300; and
(5) MAA-approved structured weight loss programs. See also WAC 388-531-1600.
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(l) MAA covers inpatient chronic pain management services only when the services are obtained through an MAA-approved chronic pain facility.
(2) A client qualifies for inpatient chronic pain management services when all of the following apply:
(a) The client has had chronic pain for at least three months, that has not improved with conservative treatment, including tests and therapies;
(b) At least six months have passed since a previous surgical procedure was done in relation to the pain problem; and
(c) Clients with active substance abuse must have completed a detoxification program, if appropriate, and must be free from drugs or alcohol for six months.
(3) For chronic pain management, MAA limits coverage to only one inpatient hospital stay per client's lifetime, up to a maximum of twenty-one days.
(4) MAA reimburses for only the chronic pain management services and procedures that are listed in the fee schedule.
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(1) MAA separately reimburses the attending provider for inpatient hospital professional services rendered by the attending provider during the surgical follow-up period only if the services are performed for an emergency condition or a diagnosis that is unrelated to the inpatient stay.
(2) MAA reimburses for only one inpatient hospital call per client, per day for the same or related diagnoses. If a call is included in the global surgery reimbursement, MAA does not reimburse separately.
(3) MAA reimburses a hospital admission related to a planned surgery through the global fee for surgery.
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(1) MAA reimburses providers for laboratory services only when they are:
(a) Are certified according to Title XVII of the Social Security Act (Medicare), if required; and
(b) Have a clinical laboratory improvement amendment (CLIA) certificate and identification number.
(2) MAA includes a handling, packaging, and mailing fee in the reimbursement for lab tests and does not reimburse these separately.
(3) MAA reimburses only one blood drawing fee per client, per day. MAA allows additional reimbursement for an independent laboratory when it goes to a nursing facility or a private home to obtain a specimen.
(4) MAA reimburses only one catheterization for collection of a urine specimen per client, per day.
(5) MAA reimburses automated multichannel tests done alone or as a group, as follows:
(a) The provider must bill a panel if all individual tests are performed. If not all tests are performed, the provider must bill individual tests.
(b) If the provider bills one automated multichannel test, MAA reimburses the test at the individual procedure code rate, or the internal code maximum allowable fee, whichever is lower.
(c) Tests may be performed in a facility that owns or leases automated multichannel testing equipment. The facility may be any of the following:
(i) A clinic;
(ii) A hospital laboratory;
(iii) An independent laboratory; or
(iv) A physician's office.
(6) MAA allows a STAT fee in addition to the maximum allowable fee when a laboratory procedure is performed STAT.
(a) MAA reimburses STAT charges for only those procedures identified by the clinical laboratory advisory council as appropriate to be performed STAT.
(b) Tests generated in the emergency room do not automatically justify a STAT order, the physician must specifically order the tests as STAT.
(c) Refer to the fee schedule for a list of STAT procedures.
(7) MAA reimburses for drug screen charges only when medically necessary and when ordered by a physician as part of a total medical evaluation.
(8) MAA does not reimburse for drug screens for clients in the division of alcohol and substance abuse (DASA)-contracted methadone treatment programs. These are reimbursed through a contract issued by DASA.
(9) MAA does not cover for drug screens to monitor any of the following:
(a) Program compliance in either a residential or outpatient drug or alcohol treatment program;
(b) Drug or alcohol abuse by a client when the screen is performed by a provider in private practice setting; or
(c) Suspected drug use by clients in a residential setting, such as a group home.
(10) MAA may require a drug or alcohol screen in order to determine a client's suitability for a specific test.
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(1) MAA pays for clinical diagnostic laboratory procedures based on the Medicare clinical diagnostic laboratory fee schedule (MCDLF) for the state of Washington. MAA obtains information used to update fee schedule regulations from Program Memorandum and Regional Medicare Letters as published by HCFA.
(2) MAA updates budget-neutral fees each July by:
(a) Determining the units of service and expenditures for a base period. Then,
(b) Determining in total the ratio of current MAA fees to existing Medicare fees. Then,
(c) Determining new MAA fees by adjusting the new Medicare fee by the ratio. Then,
(d) Multiplying the units of service by the new MAA fee to obtain total estimated expenditures. Then,
(e) Comparing the expenditures in subsection (14)(d) of this section to the base period expenditures. Then,
(f) Adjusting the new ratio until estimated expenditures equals the base period amount.
(3) MAA calculates maximum allowable fees (MAF) by:
(a) Calculating fees using methodology described in subsection (2) of this section for procedure codes that have an applicable Medicare clinical diagnostic laboratory fee (MCDLF).
(b) Establishing RSC fees for procedure codes that have no applicable MCDLF.
(c) Establishing maximum allowable fees, or "flat fees" for procedure codes that have no applicable MCDLF or RSC fees. MAA updates flat fee reimbursement only when authorized by the legislature.
(d) MAA reimbursement for clinical laboratory diagnostic procedures does not exceed the regional MCDLF schedule.
(4) MAA increases fees if the legislature grants a vendor rate increase or other increase. If the legislatively authorized increase becomes effective at the same time as MAA's annual update, MAA applies the increase after calculating budget-neutral fees.
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(1) MAA pays the physician directing the care of a neonate or infant in an NICU, for NICU services.
(2) NICU services include, but are not limited to, any of the following:
(a) Patient management;
(b) Monitoring and treatment of the neonate, including nutritional, metabolic and hematologic maintenance;
(c) Parent counseling; and
(d) Personal direct supervision by the health care team of activities required for diagnosis, treatment, and supportive care of the patient.
(3) Payment for NICU care begins with the date of admission to the NICU.
(4) MAA reimburses a provider for only one NICU service per client, per day.
(5) A provider may bill for NICU services in addition to prolonged services and newborn resuscitation when the provider is present at the delivery.
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(l) MAA reimburses for the following:
(a) Two calls per month for routine conditions in a nursing facility; and.
(b) One call per client, per day, per individual physician, except for valid call-backs to the emergency room per WAC 388-531-0500.
(2) The provider must provide justification based on medical necessity at the time of billing for visits in excess of subsection (l) of this section.
(3) See physician billing instructions for procedures that are included in the office call and cannot be billed separately.
(4) Using selected diagnosis codes, MAA reimburses the provider at the appropriate level of physician office call for history and physical procedures in conjunction with dental surgery services performed in an outpatient setting.
(5) MAA may reimburse providers for injection procedures and/or injectable drug products only when:
(a) The injectable drug is administered during an office visit; and
(b) The injectable drug used is from office stock and purchased from a pharmacist or drug manufacturer as described in WAC 388-530-1200.
(6) MAA does not reimburse a prescribing provider for a drug when a pharmacist dispenses the drug.
(7) MAA does not reimburse the prescribing provider for an immunization when the immunization material is received from the department of health; MAA does reimburse an administrative fee. If the immunization is given in a health department and is the only service provided, MAA reimburses a minimum E&M service.
(8) MAA reimburses immunizations at estimated acquisition costs (EAC) when the immunizations are not part of the vaccine for children program. MAA reimburses a separate administration fee for these immunizations. Covered immunizations are listed in the fee schedule.
(9) MAA reimburses therapeutic and diagnostic injections subject to certain limitations as follows:
(a) MAA does not separately reimburse for intra-arterial and intravenous therapeutic or diagnostic injections provided in conjunction with intravenous infusion therapy services. MAA does reimburse separately for these injections when they are provided on the same day as an E&M service.
(b) MAA does not reimburse separately for subcutaneous or intramuscular antibiotic injections provided on the same day as an E&M service. If the injection is the only service provided, MAA covers the injection service. MAA reimburses separately for the drug.
(c) MAA reimburses injectable drugs at acquisition cost. The provider must document the name, strength, and dosage of the drug and retain that information in the client's file. The provider must provide an invoice when requested by MAA. This subsection does not apply to drugs used for chemotherapy; see subsection (11) in this section for chemotherapy drugs.
(d) The provider must submit a manufacturer's invoice and to document the name, strength, and dosage on the claim form when billing MAA for the following drugs:
(i) Classified drugs that cost over one thousand, one hundred dollars;
(ii) Unclassified drugs that cost over one hundred dollars; and
(iii) Unclassified antineoplastic drugs that cost over five hundred dollars.
(10) MAA reimburses allergen immunotherapy only as follows:
(a) Antigen/antigen preparation codes are reimbursed per dose.
(b) The provider must bill the total number of doses in a multiple dose vial.
(c) When remaining doses of a multiple dose vial are injected at subsequent times, MAA reimburses the injection service only.
(d) MAA covers both the injection and the antigen/antigen preparation code.
(e) MAA reimburses a provider separately for an E&M service if there is a diagnosis for conditions unrelated to allergen immunotherapy.
(f) MAA reimburses for RAST testing when the physician has written documentation in the client's record indicating that previous skin testing failed and was negative.
(11) Chemotherapy drugs.
(a) MAA reimburses for chemotherapy drugs administered in the physician's office only when:
(i) The physician personally supervises the E&M services furnished by office medical staff; and
(ii) The medical record reflects the physician's active participation in or management of course of treatment.
(b) MAA establishes a maximum allowable based on its pricing of the estimated acquisition cost (EAC).
(12) Notwithstanding the provisions of this section, MAA reserves the option of determining drug pricing for any particular drug based on the best evidence available to MAA regarding the actual cost, after discounts and promotions, paid by typical providers nationally or in Washington state.
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(1) MAA covers opthalmological services furnished by a provider as listed in WAC 388-531-0250, and subject to the limitations in this section and other published WAC.
(2) MAA requires expedited prior authorization for strabismus surgery for clients eighteen years of age and older.
(3) MAA does not cover any of the following:
(a) Orthoptics and visual training therapy;
(b) Two pairs of eyeglasses;
(c) E&M services billed in combination with eye exam procedure codes;
(d) Radial Keratotomy or other surgery for refractive purposes;
(e) Refractive prescriptions over two years old; or
(f) Group screening for eyeglasses (except for EPSDT).
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(1) MAA reimburses osteopathic manipulative therapy (OMT) only when OMT is provided by an osteopathic physician licensed under chapter 18.71 RCW.
(2) MAA reimburses OMT only when the provider bills using the appropriate CPT codes that involve the number of body regions involved.
(3) MAA allows an osteopathic physician to bill MAA for an E&M service in addition to the OMT when one of the following apply:
(a) The physician diagnoses the condition requiring manipulative therapy and provides it during the same visit;
(b) The existing related diagnosis or condition fails to respond to manipulative therapy or the condition significantly changes or intensifies, requiring E/M services beyond those included in the manipulation codes; or
(c) The physician treats the client during the same encounter for an unrelated condition that does not require manipulative therapy.
(4) MAA limits reimbursement for manipulations to ten per client, per calendar year. Reimbursement for each manipulation includes a brief evaluation as well as the manipulation.
(5) MAA does not reimburse for physical therapy services performed by osteopathic physicians.
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(1) MAA covers medical services provided to Medicaid clients who are temporarily located outside the state, subject to the provisions of this chapter and WAC 388-501-0180.
(2) Out-of-state border areas as described under WAC 388-501-0175 are not subject to out-of-state limitations. MAA considers physicians in border areas as providers in the state of Washington.
(3) In order to be eligible for reimbursement, out-of-state physicians must meet all criteria for, and must comply with all procedures required of in-state physicians, in addition to other requirements of this chapter.
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(1) MAA covers physician care plan oversight services only when:
(a) A physician provides the service; and
(b) The client is served by a home health agency, a nursing facility, or a hospice.
(2) MAA reimburses for physician care plan oversight services when both of the following apply:
(a) The facility/agency has established a plan of care; and
(b) The physician spends thirty or more minutes per calendar month providing oversight for the client's care.
(3) MAA reimburses only one physician per client, per month, for physician care plan oversight services.
(4) MAA reimburses for physician care plan oversight services during the global surgical reimbursement period only when the care plan oversight is unrelated to the surgery.
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(1) Refer to RBRVS billing instructions for a list of:
(a) Supplies that are a routine part of office or other outpatient procedures and that cannot be billed separately; and
(b) Supplies that can be billed separately and that MAA considers nonroutine to office or outpatient procedures.
(2) MAA reimburses at acquisition cost certain supplies under fifty dollars that do not have a maximum allowable fee listed in the fee schedule. The provider must retain invoices for these items and make them available to MAA upon request.
(3) Providers must submit invoices for items costing fifty dollars or more.
(4) MAA reimburses for sterile tray for certain surgical services only. Refer to the fee schedule for a list of covered items.
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(1) MAA reimburses physician standby services only when the standby physician does not provide care or service to other clients during this period, and either:
(a) The services are provided in conjunction with newborn care history and examination, or result in an admission to a neonatal intensive care unit on the same day; or
(b) A physician requests another physician to stand by, resulting in the prolonged attendance by the second physician without face-to-face client contact.
(2) MAA does not reimburse physician standby services when any of the following occur:
(a) The standby ends in a surgery or procedure included in a global surgical reimbursement;
(b) The standby period is less than thirty minutes; or
(c) Time is spent proctoring another physician.
(3) One unit of physician standby service equals thirty minutes. MAA reimburses subsequent periods of physician standby service only when full thirty minutes of standby is provided for each unit billed. MAA rounds down fractions of a thirty-minute time unit.
(4) The provider must clearly document the need for physician standby services in the client's medical record.
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(1) MAA covers podiatric services as listed in this section when provided by any of the following:
(a) A medical doctor;
(b) A doctor of osteopathy; or
(c) A podiatric physician.
(2) MAA reimburses for the following:
(a) Nonroutine foot care when a medical condition that affects the feet (such as diabetes or arteriosclerosis obliterans) requires that any of the providers in subsection (1) of this section perform such care;
(b) One treatment in a sixty-day period for debridement of nails. MAA covers additional treatments in this period if documented in the client's medical record as being medically necessary;
(c) Impression casting. MAA includes ninety-day follow-up care in the reimbursement;
(d) A surgical procedure performed on the ankle or foot, requiring a local nerve block, and performed by a qualified provider. MAA does not reimburse separately for the anesthesia, but includes it in the reimbursement for the procedure; and
(e) Custom fitted and/or custom molded orthotic devices:
(i) MAA's fee for the orthotic device includes reimbursement for a biomechanical evaluation (an evaluation of the foot that includes various measurements and manipulations necessary for the fitting of an orthotic device); and
(ii) MAA includes an E&M fee reimbursement in addition to an orthotic fee reimbursement if the E&M services are justified and well documented in the client's medical record.
(3) MAA does not reimburse podiatrists for any of the following radiology services:
(a) X-rays for soft tissue diagnosis;
(b) Bilateral x-rays for a unilateral condition;
(c) X-rays in excess of two views;
(d) X-rays that are ordered before the client is examined; or
(e) X-rays for any part of the body other than the foot or ankle.
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(1) MAA reimburses prolonged services based on established Medicare guidelines. The services provided may or may not be continuous. The services provided must meet both of the following:
(a) Consist of face-to-face contact between the physician and the client; and
(b) Be provided with other services.
(2) MAA allows reimbursement for a prolonged service procedure in addition to an E&M procedure or consultation, up to three hours per client, per diagnosis, per day, subject to other limitations in the CPT codes that may be used. The applicable CPT codes are indicated in the fee schedule.
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(1) MAA limits psychotherapy to one hour per day, per client, up to a total of twelve hours per calendar year. This includes family or group psychotherapy. Psychotherapy must be provided by a psychiatrist in the office, in the client's home, or in a nursing facility.
(2) MAA reimburses only one hospital call for direct psychiatric client care, per client, per day. Psychiatrists must bill the total time spent on direct psychiatric client care during each visit. Making rounds is considered direct client care and includes any one of the following:
(a) Brief (up to one hour), individual psychotherapy;
(b) Family/group therapy;
(c) Electroconvulsive therapy; or
(d) Pharmacologic management.
(3) MAA reimburses psychiatrists for either hospital care or psychotherapy, but not for both on the same day.
(4) MAA reimburses psychiatrists for a medical physical examination in the hospital in addition to a psychiatric diagnostic or evaluation interview examination.
(5) MAA reimburses only one psychiatric diagnostic interview examination in a calendar year unless a significant change in the client's circumstances renders such a evaluation medically necessary.
(6) MAA requires psychiatrists to use hospital E&M codes when billing for daily rounds.
(7) MAA does not cover for psychiatric sleep therapy.
(8) Medication adjustment is the only psychiatric service for which MAA reimburses psychiatric ARNPs.
(9) MAA reimburses for one interactive or insight oriented call per client, per day, in an office or outpatient setting. Individual psychotherapy, interactive services may be billed only for clients age twenty and younger.
(10) DSHS providers must comply with chapters 275-55 and 275-57 WAC for hospital inpatient psychiatric admissions, and must follow rules adopted by the division of mental health or the appropriate regional support network (RSN). MAA does not reimburse for those psychiatric services that are eligible for reimbursement under those agencies.
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(1) MAA reimburses radiology services subject to the limitations in this section and under WAC 388-531-0300.
(2) MAA does not make separate payments for contrast material. The exception is low osmolar contrast media (LOCM) used in intrathecal, intravenous, and intra-arterial injections. Clients receiving these injections must have one or more of the following conditions:
(a) A history of previous adverse reaction to contrast material. An adverse reaction does not include a sensation of heat, flushing, or a single episode of nausea or vomiting;
(b) A history of asthma or allergy;
(c) Significant cardiac dysfunction including recent or imminent cardiac decompensation, severe arrhythmias, unstable angina pectoris, recent myocardial infarction, and pulmonary hypertension;
(d) Generalized severe debilitation;
(e) Sickle cell disease;
(f) Pre-existing renal insufficiency; and/or
(g) Other clinical situations where use of any media except LOCM would constitute a danger to the health of the client.
(3) MAA reimburse separately for radiopharmaceutical diagnostic imaging agents for nuclear medicine procedures. Providers must submit invoices for these procedures when requested by MAA, and reimbursement is at acquisition cost.
(4) MAA reimburses general anesthesia for radiology procedures. See WAC 388-531-0300.
(5) MAA reimburses radiology procedures in combination with other procedures according to the rules for multiple surgeries. See WAC 388-531-1700. The procedures must meet all of the following conditions:
(a) Performed on the same day;
(b) Performed on the same client; and
(c) Performed by the same physician or more than one member of the same group practice.
(6) MAA reimburses consultation on X-ray examinations. The consulting physician must bill the specific radiological X-ray code with the appropriate professional component modifier.
(7) MAA reimburses for portable x-ray services furnished in the client's home or in nursing facilities, limited to the following:
(a) Chest or abdominal films that do not involve the use of contract media;
(b) Diagnostic mammograms; and
(c) Skeletal films involving extremities, pelvis, vertebral column or skull.
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(1) MAA covers sleep studies only when all of the following apply:
(a) The study is done to establish a diagnosis of narcolepsy or of sleep apnea;
(b) The study is done only at an MAA-approved sleep study center that meets the standards and conditions in subsections (2), (3), and (4) of this section; and
(c) An ENT consultation has been done for a client under ten years of age.
(2) In order to become an MAA-approved sleep study center, a sleep lab must send MAA verification of both of the following:
(a) Sleep lab accreditation by the American Academy of Sleep Medicine; and
(b) Physician's Board Certification by the American Board of Sleep Medicine.
(3) Registered polysomnograph technicians (PSGT) must meet the accreditation standards of the American Academy of Sleep Medicine.
(4) When a sleep lab changes directors, MAA requires the provider to submit accreditation for the new director. If an accredited director moves to a facility that MAA has not approved, the provider must submit certification for the facility.
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(1) For purposes of this section, sterilization is any medical procedure, treatment, or operation for the purpose of rendering a client permanently incapable of reproducing. A hysterectomy is a surgical procedure or operation for the purpose of removing the uterus. Hysterectomy results in sterilization, but MAA does not cover hysterectomy performed solely for that purpose. Both hysterectomy and sterilization procedures require the use of specific consent forms.
STERILIZATION
(2) MAA covers sterilization when all of the following apply:
(a) The client is at least eighteen years of age at the time consent is signed;
(b) The client is a mentally competent individual;
(c) The client has voluntarily given informed consent in accordance with all the requirements defined in this subsection; and
(d) At least thirty days, but not more than one hundred eighty days, have passed between the date the client gave informed consent and the date of the sterilization.
(3) MAA does not require the thirty-day waiting period, but does require at least a seventy-two hour waiting period, for sterilization in the following circumstances:
(a) At the time of premature delivery, the client gave consent at least thirty days before the expected date of delivery. The expected date of delivery must be documented on the consent form;
(b) For emergency abdominal surgery, the nature of the emergency must be described on the consent form.
(4) MAA waives the thirty-day consent waiting period for sterilization when the client requests that sterilization be performed at the time of delivery, and completes a sterilization consent form. One of the following circumstances must apply:
(a) The client became eligible for medical assistance during the last month of pregnancy;
(b) The client did not obtain medical care until the last month of pregnancy; or
(c) The client was a substance abuser during pregnancy, but is not using alcohol or illegal drugs at the time of delivery.
(5) MAA does not accept informed consent obtained when the client is in any of the following conditions:
(a) In labor or childbirth;
(b) Seeking to obtain or obtaining an abortion; or
(c) Under the influence of alcohol or other substances that affect the client's state of awareness.
(6) MAA has certain consent requirements that the provider must meet before MAA reimburses sterilization of a mentally incompetent or institutionalized client. MAA requires both of the following:
(a) A court order; and
(b) A sterilization consent form signed by the legal guardian, sent to MAA at least thirty days prior to the procedure.
(7) MAA reimburses epidural anesthesia in excess of the six-hour limit for sterilization procedures that are performed in conjunction with or immediately following a delivery. MAA determines total billable units by:
(a) Adding the time for the sterilization procedure to the time for the delivery; and
(b) Determining the total billable units by adding together the delivery BAUs, the delivery time, and the sterilization time.
(c) The provider cannot bill separately for the BAUs for the sterilization procedure.
(8) The physician identified in the "consent to sterilization" section of the DSHS-approved sterilization consent form must be the same physician who completes the "physician's statement" section and performs the sterilization procedure. If a different physician performs the sterilization procedure, the client must sign and date a new consent form at the time of the procedure that indicates the name of the physician performing the operation under the "consent for sterilization" section. This modified consent must be attached to the original consent form when the provider bills MAA.
(9) MAA reimburses all attending providers for the sterilization procedure only when the provider submits an appropriate, completed DSHS-approved consent form with the claim for reimbursement. MAA reimburses after the procedure is completed.
HYSTERECTOMY
(10) Hysterectomies performed for medical reasons may require expedited prior authorization as explained in WAC 388-531-0200(2).
(11) MAA reimburses authorization in either of the following circumstances:
(a) The client has been diagnosed with cancer(s) of the female reproductive organs; and/or
(b) The client is forty-six years of age or older.
(12) MAA reimburses all attending providers for the hysterectomy procedure only when the provider submits an appropriate, completed DSHS-approved consent form with the claim for reimbursement. If a prior authorization number is necessary for the procedure, it must be on the claim. MAA reimburses after the procedure is completed.
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MAA covers structured outpatient weight loss only through an MAA-approved program.
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(1) MAA reimburses substance abuse detoxification services under state-unique codes.
(2) MAA covers physician services for three-day alcohol detoxification or five-day drug detoxification services for a client eligible for medical care program services in an MAA-enrolled hospital-based detoxification center.
(3) MAA covers treatment in programs qualified under chapter 275-25 WAC and certified under chapter 275-19 WAC or its successor.
(4) MAA covers detoxification and medical stabilization services to chemically using pregnant (CUP) women for up to twenty-seven days in an inpatient hospital setting.
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(1) MAA's global surgical reimbursement for all covered surgeries includes all of the following:
(a) The operation itself;
(b) Postoperative dressing changes, including:
(i) Local incision care and removal of operative packs;
(ii) Removal of cutaneous sutures, staples, lines, wire, tubes, drains, and splints;
(iii) Insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; or
(iv) Change and removal of tracheostomy tubes.
(c) All additional medical or surgical services required because of complications that do not require additional operating room procedures.
(2) MAA's global surgical reimbursement for major surgeries, includes all of the following:
(a) Preoperative visits, in or out of the hospital, beginning on the day before surgery; and
(b) Services by the primary surgeon, in or out of the hospital, during a standard ninety-day postoperative period.
(3) MAA's global surgical reimbursement for minor surgeries includes all of the following:
(a) Preoperative visits beginning on the day of surgery; and
(b) Follow-up care for zero or ten days, depending on the procedure.
(4) When a second physician provides follow-up services for minor procedures performed in hospital emergency departments, MAA does not include these services in the global surgical reimbursement. The physician may bill these services separately.
(5) MAA's global surgical reimbursement for multiple surgical procedures is as follows:
(a) Payment for multiple surgeries performed on the same client on the same day equals one hundred percent of MAA's allowed fee for the highest value procedure. Then,
(b) For additional surgical procedures, payment equals fifty percent of MAA's allowed fee for each procedure.
(6) MAA allows separate reimbursement for any of the following:
(a) The initial evaluation or consultation;
(b) Preoperative visits more than one day before the surgery;
(c) Postoperative visits for problems unrelated to the surgery; and
(d) Postoperative visits for services that are not included in the normal course of treatment for the surgery.
(7) MAA's reimbursement for endoscopy is as follows:
(a) The global surgical reimbursement fee includes follow-up care for zero or ten days, depending on the procedure.
(b) Multiple surgery rules apply when a provider bills multiple endoscopies from different endoscopy groups. See subsection (4) of this section.
(c) When a physician performs more than one endoscopy procedure from the same group on the same day, MAA pays the full amount of the procedure with the highest maximum allowable fee.
(d) MAA pays the procedure with the second highest maximum allowable fee at the maximum allowable fee minus the base diagnostic endoscopy procedure's maximum allowed amount.
(e) MAA does not pay when payment for other codes within an endoscopy group is less than the base code
(8) MAA restricts reimbursement for surgery assists to selected procedures as follows:
(a) MAA applies multiple surgery reimbursement rules for surgery assists apply. See subsection (4) of this section.
(b) Surgery assists are reimbursed at twenty percent of the maximum allowable fee for the surgical procedure.
(c) A surgical assist fee for a registered nurse first assistant (RNFA) is reimbursed if the nurse has been assigned a provider number.
(d) A provider must use a modifier on the claim with the procedure code to identify surgery assist.
(9) MAA bases payment splits between preoperative, intraoperative, and postoperative services on Medicare determinations for given surgical procedures or range of procedures. MAA pays any procedure that does not have an established Medicare payment split according to a split of ten percent - eighty percent - ten percent respectively.
(10) For preoperative and postoperative critical care services provided during a global period refer to WAC 388-531-0450.
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MAA covers transplants when performed in an MAA-approved center of excellence. See WAC 388-550-1900 for information regarding transplant coverage.
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See WAC 388-550-2000 for information about medical criteria to receive transplants.
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GENERAL PAYMENT METHODOLOGY
(l) MAA bases the payment methodology for most physician-related services on Medicare's RBRVS. MAA obtains information used to update MAA's RBRVS from the MPFSPS.
(2) MAA updates and revises the following RBRVS areas each January prior to MAA's annual update.
(3) MAA determines a budget-neutral conversion factor (CF) for each RBRVS update, by:
(a) Determining the units of service and expenditures for a base period. Then,
(b) Applying the latest Medicare RVU obtained from the MPFSDB, as published in the MPFSPS, and GCPI changes to obtain projected units of service for the new period. Then,
(c) Multiplying the projected units of service by conversion factors to obtain estimated expenditures. Then,
(d) Comparing expenditures obtained in (c) of this subsection with base period expenditure levels.
(e) Adjusting the dollar amount for the conversion factor until the product of the conversion factor and the projected units of service at the new RVUs equals the base period amount.
(4) MAA calculates maximum allowable fees (MAFs) in the following ways:
(a) For procedure codes that have applicable Medicare RVUs, the three components (practice, malpractice, and work) of the RVU are:
(i) Each multiplied by the statewide GPCI. Then,
(ii) The sum of these products is multiplied by the applicable conversion factor. The resulting RVUs are known as RBRVS RVUs.
(b) For procedure codes that have no applicable Medicare RVUs, RSC RVUs are established in the following way:
(i) When there are three RSC RVU components (practice, malpractice, and work):
(A) Each component is multiplied by the statewide GPCI. Then,
(B) The sum of these products is multiplied by the applicable conversion factor.
(ii) When the RSC RVUs have just one component, the RVU is not GPCI adjusted and the RVU is multiplied by the applicable conversion factor.
(c) For procedure codes with no RBRVS or RSC RVUs, MAA establishes maximum allowable fees, also known as "flat" fees.
(i) MAA does not use the conversion factor for these codes.
(ii) MAA updates flat fee reimbursement only when the legislature authorizes a vendor rate increase, except for the following categories which are revised annually during the update:
(A) Immunization codes are reimbursed at EAC. (See WAC 388-530-1050 for explanation of EAC.) When the provider receives immunization materials from the department of health, MAA pays the provider a flat fee only for administering the immunization.
(B) A cast material maximum allowable fee is set using an average of wholesale or distributor prices for cast materials.
(iii) Other supplies are reimbursed at physicians' acquisition cost, based on manufacturers' price sheets. Reimbursement applies only to supplies that are not considered part of the routine cost of providing care (e.g., intrauterine devices (IUDs)).
(d) For procedure codes with no RVU or maximum allowable fee, MAA reimburses "by report." By report codes are reimbursed at a percentage of the amount billed for the service.
(e) For supplies that are dispensed in a physician's office and reimbursed separately, the provider's acquisition cost when flat fees are not established.
(f) MAA reimburses at acquisition cost those HCPCS J and Q codes that do not have flat fees established.
(5) The technical advisory group reviews RBRVS changes.
(6) MAA also makes fee schedule changes when the legislature grants a vendor rate increase and the effective date of that increase is not the same as MAA's annual update.
(7) If the legislatively authorized vendor rate increase, or other increase, becomes effective at the same time as the annual update, MAA applies the increase after calculating budget-neutral fees. MAA pays providers a higher reimbursement rate for primary health care E&M services that are provided to children age twenty and under.
(8) MAA does not allow separate reimbursement for bundled services. However, MAA allows separate reimbursement for items considered prosthetics when those items are used for a permanent condition and are furnished in a provider's office.
(9) Variations of payment methodology which are specific to particular services and which differ from the general payment methodology described in this section are included in the sections dealing with those particular services.
CPT/HCFA MODIFIERS
(10) A modifier is a code a provider uses on a claim in addition to a billing code for a standard procedure. Modifiers eliminate the need to list separate procedures that describe the circumstance that modified the standard procedure. A modifier may also be used for information purposes.
(11) Certain services and procedures require modifiers in order for MAA to reimburse the provider. This information is included in the sections dealing with those particular services and procedures, as well as the fee schedule.
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(1) MAA reimburses physicians and related providers for covered services provided to eligible clients on a fee-for-service basis, subject to the exceptions, restrictions, and other limitations listed in this chapter and other published issuances.
(2) In order to be reimbursed, physicians must bill MAA according to the conditions of payment under WAC 388-501-0150 and other issuances.
(3) MAA does not separately reimburse certain administrative costs or services. MAA considers these costs to be included in the reimbursement. These costs and services include the following:
(a) Delinquent payment fees;
(b) Educational supplies;
(c) Mileage;
(d) Missed or canceled appointments;
(e) Reports, client charts, insurance forms, copying expenses;
(f) Service charges;
(g) Take home drugs; and
(h) Telephoning (e.g., for prescription refills).
(4) MAA does not routinely pay for procedure codes which have a "#" indicator in the fee schedule. MAA reviews these codes for conformance to Medicaid program policy only as an exception to policy or as a limitation extension. See WAC 388-501-0160 and 388-501-0165.
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The following sections of the Washington Administrative Code are repealed:
| WAC 388-86-011 | Advanced registered nurse practitioners (ARNP) services. |
| WAC 388-86-055 | Laboratory services. |
| WAC 388-86-095 | Physician services. |
| WAC 388-86-09601 | Podiatric services. |
| WAC 388-86-110 | X-ray services. |
| WAC 388-87-075 | Payment -- Laboratory services. |
| WAC 388-87-095 | Payment -- Physician service. |