"National correct coding initiative (NCCI)" is a national standard for the accurate and consistent description of medical goods and services using procedural codes. The standard is based on coding conventions defined in the American Medical Association's Current Procedural Terminology (CPT®) manual, current standards of medical and surgical coding practice, input from specialty societies, and analysis of current coding practices. The Centers for Medicare and Medicaid Services (CMS) maintain NCCI policy. Information can be found at: http://www.cms.hhs.gov/NationalCorrectCodInitEd/.

"National provider indicator (NPI)" is a federal system for uniquely identifying all providers of health care services, supplies, and equipment.

"NCCI edit" is a software step used to determine if a claim is billing for a service that is not in accordance with federal and state statutes, federal and state regulations, agency or the agency's designee's fee schedules, billing instructions, and other publications. The agency or the agency's designee has the final decision whether the NCCI edits allow automated payment for services that were not billed in accordance with governing law, NCCI standards or agency or agency's designee policy.

"Nonapplying spouse" see "spouse" in WAC 182-500-0100.

"Nonbilling provider" is a health care professional enrolled with the agency only as an ordering, referring, prescribing provider for the Washington medicaid program and who is not otherwise enrolled as a medicaid provider with the agency.

"Noncovered service" see "covered service" in WAC 182-500-0020.

"Nursing facility" see "institution" in WAC 182-500-0050.

"Nursing facility long-term care services" are services in a nursing facility when a person does not meet the criteria for rehabilitation. Most long-term care assists people with support services. (Also called custodial care.)

"Nursing facility rehabilitative services" are the planned interventions and procedures which constitute a continuing and comprehensive effort to restore a person to the person's former functional and environmental status, or alternatively, to maintain or maximize remaining function.

(1) The purpose of the medicaid agency's home health program is to reduce the costs of health care services by providing equally effective, less restrictive quality care to the client in ((the client's residence))any setting where normal life activities take place, subject to the restrictions and limitations in subchapter II.

(3) Home health skilled services are provided for acute, intermittent, short-term, and intensive courses of treatment. See chapters 182-514 and 388-71 WAC for programs administered to clients who need chronic, long-term maintenance care.

The following definitions and abbreviations and those found in chapter 182-500 WAC apply to subchapter II:

"Acute care" means care provided by a home health agency for clients who are not medically stable or have not attained a satisfactory level of rehabilitation. These clients require frequent intervention by a registered nurse or licensed therapist.

"Brief skilled nursing visit" means a registered nurse, or a licensed practical nurse under the supervision of a registered nurse, performs only one of the following activities during a visit to a client:

(a) An injection;

(b) Blood draw; or

(c) Placement of medications in containers.

"Chronic care" means long-term care for medically stable clients.

"Full skilled nursing visit" means a registered nurse, or a licensed practical nurse under the supervision of a registered nurse, performs one or more of the following activities during a visit to a client:

(a) Observation;

(b) Assessment;

(c) Treatment;

(d) Teaching;

(e) Training;

(f) Management; and

(g) Evaluation.

"Home health agency" means an agency or organization certified under medicare to provide comprehensive health care on an intermittent or part-time basis to a patient in any setting where the patient's normal life activities take place ((of residence)).

"Home health aide" means a person registered or certified as a nursing assistant under chapter 18.88 RCW who, under the direction and supervision of a registered nurse or licensed therapist, assists in the delivery of nursing or therapy related activities, or both.

"Home health aide services" means services provided by a home health aide only when a client has an acute, intermittent, short-term need for the services of a registered nurse, physical therapist, occupational therapist, or speech therapist who is employed by or under contract with a home health agency. These services are provided under the supervision of the previously identified authorized practitioners and include, but are not limited to, ambulation and exercise, assistance with self-administered medications, reporting changes in a client's condition and needs, and completing appropriate records.

"Home health skilled services" means skilled health care (nursing, specialized therapy, and home health aide) services provided ((in the client's residence)) on an intermittent or part-time basis by a medicare-certified home health agency with a current provider number in any setting where the client's normal life activities take place. See also WAC 182-551-2000.

"Long-term care" is a generic term referring to various programs and services, including services provided in home and community settings, administered directly or through contract by the department of social and health services' (DSHS) division of developmental disabilities (DDD) or aging and long-term support administration (ALTSA) through home and community services (HCS).

"Plan of care (POC)" (also known as "plan of treatment (POT)") means a written plan of care that is established and periodically reviewed and signed by both an ordering ((licensed practitioner))physician and a home health agency provider. The plan describes the home health care to be provided ((at the client's residence))in any setting where the client's normal life activities take place. See WAC 182-551-2210.

(("Residence" means a client's home or place of living. (See WAC 182-551-2030 (2)(g)(ii) for clients in residential facilities whose home health services are not covered through the medicaid agency's home health program.)))

"Review period" means the three-month period the medicaid agency assigns to a home health agency, based on the address of the agency's main office, during which the medicaid agency reviews all claims submitted by that home health agency.

"Specialized therapy" means skilled therapy services provided to clients that include:

(a) Physical;

(b) Occupational; or

(c) Speech/audiology services.

(See WAC 182-551-2110.)

"Telemedicine" - For the purposes of WAC 182-551-2000 through 182-551-2220, means the use of telemonitoring to enhance the delivery of certain home health skilled nursing services through:

(a) The collection and transmission of clinical data between a patient at a distant location and the home health provider through electronic processing technologies. Objective clinical data that may be transmitted includes, but is not limited to, weight, blood pressure, pulse, respirations, blood glucose, and pulse oximetry; or

(b) The provision of certain education related to health care services using audio, video, or data communication instead of a face-to-face visit.

(1) ((Persons))Clients in the Washington apple health (((WAH) fee-for-service)) programs listed in the table in WAC 182-501-0060 are eligible to receive home health services subject to the ((limitations described))provisions in this chapter. ((Persons))Clients enrolled in an agency-contracted managed care organization (MCO) receive all home health services through their designated plan.

(2) The agency ((does not)) covers home health services ((under the home health program)) for ((persons))clients in the ((CNP-emergency))alien emergency medical ((only and LCP-MNP-emergency medical only programs. The agency or its designee evaluates a request for home health skilled nursing visits on a case-by-case basis under the provisions of WAC 182-501-0165, and may cover up to two skilled nursing visits within the eligibility enrollment period if the following criteria are met:

(b) The agency or its designee authorizes up to two skilled nursing visits for follow-up care related to the emergent medical condition))program under WAC 182-507-0120.

(1) The medicaid agency ((reimburses for covered))covers home health skilled services provided to eligible clients, subject to the ((restrictions or limitations))provisions in this section and other applicable published WAC.

(2) Home health skilled services provided to eligible clients must:

(a) Meet the definition of "acute care" in WAC 182-551-2010.

(b) Provide for the treatment of an illness, injury, or disability.

(c) Be medically necessary as defined in WAC 182-500-0070.

(d) Be reasonable, based on the community standard of care, in amount, duration, and frequency.

(e) Meet face-to-face requirements described in WAC 182-551-2040.

(f) Be provided under a plan of care (POC), as defined in WAC 182-551-2010 and described in WAC 182-551-2210. Any statement in the POC must be supported by documentation in the client's medical records.

(((f)))(g) Be used to prevent placement in a more restrictive setting. In addition, the client's medical records must justify the medical ((reason(s)))reason or reasons that the services should be provided ((in the client's residence))and why instructing the client would be most effectively done in any setting where the client's normal life activities take place instead of at an ordering ((licensed practitioner's))physician's office, clinic, or other outpatient setting. ((This includes justification for services for a client's medical condition that requires teaching that would be most effectively accomplished in the client's home on a short-term basis.

(g)))(h) Be provided in ((the client's residence))any setting where normal life activities take place.

(i) The medicaid agency does not ((reimburse))pay for services ((if)) provided at ((the workplace, school, child day care))a hospital, adult day care, skilled nursing facility, intermediate care facility for individuals with intellectual disabilities, or any ((other place that is not the client's place of residence))setting in which payment is or could be made under medicaid for inpatient services that include room and board.

(ii) Clients in residential facilities contracted with the state and paid by other programs, such as home and community programs to provide limited skilled nursing services, are not eligible for medicaid agency-funded, limited skilled nursing services unless the services are prior authorized under WAC 182-501-0165.

(((h)))(i) Be provided by:

(i) A home health agency that is Title XVIII (medicare)-certified;

(ii) A registered nurse (RN) prior authorized by the medicaid agency when no home health agency exists in the area where a client resides; or

(iii) An RN authorized by the medicaid agency when the RN cannot contract with a medicare-certified home health agency.

(1) The medicaid agency pays for home health services provided under this chapter only when the face-to-face encounter requirements in this section are met.

(2) For initiation of home health services, with the exception of medical equipment under WAC 182-551-2122, the face-to-face encounter must be related to the primary reason the client requires home health services and must occur within ninety days before or within the thirty days after the start of the services.

(3) For the initiation of medical equipment under WAC 182-551-2122, the face-to-face encounter must be related to the primary reason the client requires medical equipment and must occur no later than six months prior to the start of services.

(4) The face-to-face encounter may be conducted by the ordering physician, a nonphysician practitioner as described in WAC 182-500-0075, or the attending acute, or post-acute physician, for beneficiaries admitted to home health immediately after an acute or post-acute stay.

(5) If a nonphysician practitioner as described in WAC 182-500-0075 (or the attending physician when a client is discharged from an acute hospital stay) performs the face-to-face encounter, the nonphysician practitioner (or attending physician) must communicate the clinical findings of that face-to-face encounter to the ordering physician. Those clinical findings must be incorporated into a written or electronic document included in the client's medical record.

(6) For all home health services except medical equipment under WAC 182-551-2122, the physician responsible for ordering the services must:

(a) Document that the face-to-face encounter, which is related to the primary reason the client requires home health services, occurred within the required time frames described in subsection (2) of this section prior to the start of home health services; and

(b) Indicate the practitioner who conducted the encounter, and the date of the encounter.

(7) For medical equipment under WAC 182-551-2122, except as provided in (b) of this subsection, an ordering physician, a nonphysician practitioner as described in WAC 182-500-0075, except for certified nurse midwives, or the attending physician when a client is discharged from an acute hospital stay, must:

(a) Document that the face-to-face encounter, which is related to the primary reason the client requires home health services, occurred within the required time frames described in subsection (3) of this section prior to the start of home health services; and

(b) Indicate the practitioner who conducted the encounter, and the date of the encounter.

(8) The face-to-face encounter may occur through telemedicine. See WAC 182-551-2125.