Chapter 182-531 WAC

Last Update: 7/22/19

PHYSICIAN-RELATED SERVICES

WAC Sections

182-531-0050Physician-related services definitions.
182-531-0100Scope of coverage for physician-related and health care professional services—General and administrative.
182-531-0150Noncovered physician-related and health care professional services—General and administrative.
182-531-0200Physician-related and health care professional services requiring prior authorization.
182-531-0250Who can provide and bill for physician-related and health care professional services.
182-531-0300Anesthesia providers and covered physician-related services.
182-531-0350Anesthesia services—Reimbursement for physician-related services.
182-531-0375Audiology services.
182-531-0400Client responsibility for reimbursement for physician-related services.
182-531-0425Collaborative care.
182-531-0450Critical care—Physician-related services.
182-531-0500Emergency physician-related services.
182-531-0550Experimental and investigational services.
182-531-0600HIV/AIDS counseling and testing as physician-related services.
182-531-0650Hospital physician-related services not requiring authorization when provided in agency-approved centers of excellence or hospitals authorized to provide the specific services.
182-531-0700Inpatient chronic pain management physician-related services.
182-531-0750Inpatient hospital physician-related services.
182-531-0800Laboratory and pathology physician-related services.
182-531-0850Laboratory and pathology physician-related services reimbursement.
182-531-0900Neonatal intensive care unit (NICU) physician-related services.
182-531-0950Office and other outpatient physician-related services.
182-531-1000Ophthalmic services.
182-531-1050Manipulative therapy.
182-531-1100Out-of-state physician services.
182-531-1150Physician care plan oversight services.
182-531-1200Physician office medical supplies.
182-531-1250Physician standby services.
182-531-1300Foot care services for clients twenty-one years of age and older.
182-531-1350Prolonged physician-related service.
182-531-1400Psychiatric physician-related services and other professional mental health services.
182-531-1450Radiology physician-related services.
182-531-1500Sleep studies.
182-531-1550Sterilization physician-related services.
182-531-1600Bariatric surgery.
182-531-1625Outpatient hemophilia treatment requirements—Center of excellence.
182-531-1650Substance abuse detoxification physician-related services.
182-531-1675Washington apple health—Gender dysphoria treatment program.
182-531-1700Surgical physician-related services.
182-531-1710Alcohol and substance misuse counseling.
182-531-1720Tobacco cessation counseling.
182-531-1730Telemedicine.
182-531-1750Transplant coverage for physician-related services.
182-531-1800Transplant coverage—Medical criteria to receive transplants.
182-531-1850Payment methodology for physician-related services—General and billing modifiers.
182-531-1900Payment—General requirements for physician-related services.
182-531-2000Increased payments for physician-related services for qualified trauma cases.
182-531-2010Enhanced reimbursement—Independent advanced registered nurse practitioners (ARNPs).
182-531-2020Enhanced reimbursement—Long-acting reversible contraception (LARC).
182-531-2030Enhanced rates for pediatric care services and administration of vaccines.
182-531-2040Enhanced reimbursement—Medication assisted treatment for opioid use disorder.
DISPOSITION OF SECTIONS FORMERLY CODIFIED IN THIS TITLE
182-531-1025Oral health care services provided by dentists for clients age twenty-one and older—General. [WSR 11-14-075, recodified as § 182-531-1025, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-1025, filed 6/29/11, effective 7/30/11.] Repealed by WSR 15-03-041, filed 1/12/15, effective 2/12/15. Statutory Authority: RCW 41.05.021, 41.05.160.


182-531-0050
Physician-related services definitions.

The following definitions and abbreviations and those found in chapter 182-500 WAC, apply to this chapter.
"Acquisition cost" - The cost of an item excluding shipping, handling, and any applicable taxes.
"Acute care" - 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. See also WAC 246-335-015.
"Acute physical medicine and rehabilitation (PM&R)" - A comprehensive inpatient and rehabilitative program coordinated by a multidisciplinary team at an agency-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 182-550-2501).
"Add-on procedure(s)" - Secondary procedure(s) that are performed in addition to another procedure.
"Admitting diagnosis" - The medical condition responsible for a hospital admission, as defined by the ICD diagnostic code.
"Advanced registered nurse practitioner (ARNP)" - 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.
"Allowed charges" - The maximum amount reimbursed for any procedure that is allowed by the agency.
"Anesthesia technical advisory group (ATAG)" - An advisory group representing anesthesiologists who are affected by the implementation of the anesthesiology fee schedule.
"Bariatric surgery" - Any surgical procedure, whether open or by laparoscope, which reduces the size of the stomach with or without bypassing a portion of the small intestine and whose primary purpose is the reduction of body weight in an obese individual.
"Base anesthesia units (BAU)" - A number of anesthesia units assigned to a surgical procedure that includes the usual preoperative, intraoperative, and postoperative 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" - Services integral to the major procedure that are included in the fee for the major procedure. Bundled services are not reimbursed separately.
"Bundled supplies" - Supplies that 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)," see WAC 182-500-0015.
"Call" - 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" - A reimbursement amount based on the average cost among suppliers for one roll of cast material.
"Center of excellence (COE)" - A hospital, medical center, or other health care provider that meets or exceeds standards set by the agency for specific treatments or specialty care.
"Centers for Medicare and Medicaid Services (CMS)," see WAC 182-500-0020.
"Certified registered nurse anesthetist (CRNA)" - 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 182-542 WAC.
"Clinical Laboratory Improvement Amendment (CLIA)" - 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" - Dollar amounts the agency uses to calculate the maximum allowable fee for physician-related services.
"Covered service" - A service that is within the scope of the eligible client's medical care program, subject to the limitations in this chapter and other published WAC.
"CPT," see "current procedural terminology."
"Critical care services" - 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)" - 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).
"Emergency medical condition(s)," see WAC 182-500-0030.
"Emergency services" - Medical services required by and provided to a patient experiencing an emergency medical condition.
"Evaluation and management (E&M) codes" - Procedure codes that categorize physician services by type of service, place of service, and patient status.
"Expedited prior authorization" - The process of obtaining authorization that must be used for selected services, in which providers use a set of numeric codes to indicate to the agency which acceptable indications, conditions, diagnoses, and/or criteria are applicable to a particular request for services.
"Experimental" - A term to describe a health care service that lacks sufficient scientific evidence of safety and effectiveness. A service is not "experimental" if the service:
(a) Is generally accepted by the medical profession as effective and appropriate; and
(b) Has been approved by the federal Food and Drug Administration or other requisite government body, if such approval is required.
"Federally approved hemophilia treatment center" - A hemophilia treatment center (HTC) that:
(a) Receives funding from the U.S. Department of Health and Human Services, Maternal and Child Health Bureau National Hemophilia Program;
(b) Is qualified to participate in 340B discount purchasing as an HTC;
(c) Has a U.S. Center for Disease Control (CDC) and prevention surveillance site identification number and is listed in the HTC directory on the CDC web site;
(d) Is recognized by the Federal Regional Hemophilia Network that includes Washington state; and
(e) Is a direct care provider offering comprehensive hemophilia care consistent with treatment recommendations set by the Medical and Scientific Advisory Council (MASAC) of the National Hemophilia Foundation in their standards and criteria for the care of persons with congenital bleeding disorders.
"Fee-for-service," see WAC 182-500-0035.
"Flat fee" - The maximum allowable fee established by the agency 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 182-531-1700.
"HCPCS Level II" - Health care common procedure coding system, a coding system established by Centers for Medicare and Medicaid Services (CMS) to define services and procedures not included in CPT.
"Health care financing administration common procedure coding system (HCPCS)" - The name used for the Centers for Medicare and Medicaid Services (formerly known as the Health Care Financing Administration) codes made up of CPT and HCPCS level II codes.
"Health care team" - A group of health care providers involved in the care of a client.
"Hospice" - 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," see "International Classification of Diseases."
"Informed consent" - That an individual consents to a procedure after the provider who obtained a properly completed consent form has done all of the following:
(a) Disclosed and discussed the client's diagnosis;
(b) Offered the client an opportunity to ask questions about the procedure and to request information in writing;
(c) Given the client a copy of the consent form;
(d) Communicated effectively using any language interpretation or special communication device necessary per 42 C.F.R. Chapter IV 441.257; and
(e) Given the client oral information about all of the following:
(i) The client's right to not obtain the procedure, including potential risks, benefits, and the consequences of not obtaining the procedure;
(ii) Alternatives to the procedure including potential risks, benefits, and consequences; and
(iii) The procedure itself, including potential risks, benefits, and consequences.
"Inpatient hospital admission" - An admission to a hospital that is limited to medically necessary care based on an evaluation of the client using objective clinical indicators, assessment, monitoring, and therapeutic service required to best manage the client's illness or injury, and that is documented in the client's medical record.
"International Classification of Diseases (ICD)" - The systematic listing that transforms verbal descriptions of diseases, injuries, conditions, and procedures into numerical or alphanumerical designations (coding).
"Investigational" - A term to describe a health care service that lacks sufficient scientific evidence of safety and effectiveness for a particular condition. A service is not "investigational" if the service:
(a) Is generally accepted by the medical professional as effective and appropriate for the condition in question; or
(b) Is supported by an overall balance of objective scientific evidence, that examines the potential risks and potential benefits and demonstrates the proposed service to be of greater overall benefit to the client in the particular circumstance than another generally available service.
"Life support" - 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," see WAC 182-501-0169.
"Long-acting reversible contraceptive (LARC)" - Subdermal implants and intrauterine devices (IUDs).
"Maximum allowable fee" - The maximum dollar amount that the agency will reimburse a provider for specific services, supplies, and equipment.
"Medically necessary," see WAC 182-500-0070.
"Medication assisted treatment (MAT)" – The use of Food and Drug Administration-approved medications that have published evidence of effectiveness, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders.
"Medicare clinical diagnostic laboratory fee schedule" - The fee schedule used by medicare to reimburse for clinical diagnostic laboratory procedures in the state of Washington.
"Medicare physician fee schedule database (MPFSDB)" - The official CMS publication of the medicare policies and RVUs for the RBRVS reimbursement program.
"Medicare program fee schedule for physician services (MPFSPS)" - The official CMS publication of the medicare fees for physician services.
"Mentally incompetent" - A client who has been declared mentally incompetent by a federal, state, or local court.
"Modifier" - 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," see WAC 182-500-0080.
"Peer-reviewed medical literature" - A research study, report, or findings regarding a medical treatment that is published in one or more reputable professional journals after being critically reviewed by appropriately credentialed experts for scientific validity, safety, and effectiveness.
"Physician care plan" - 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" - 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 "current procedural terminology (CPT)."
"PM&R," see acute physical medicine and rehabilitation.
"Podiatric service" - The diagnosis and medical, surgical, mechanical, manipulative, and electrical treatments of ailments of the foot and ankle.
"Point-of-sale (POS) actual acquisition cost (AAC)" - The agency determined rate paid to pharmacies through the POS system, which is intended to reflect pharmacy providers' actual acquisition cost.
"Pound indicator (#)" - A symbol (#) indicating a CPT procedure code listed in the agency's fee schedules that is not routinely covered.
"Preventive" - 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," see WAC 182-500-0085.
"Professional component" - 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" - 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" - 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 182-500-0085.
"Radioallergosorbent test" or "RAST" - A blood test for specific allergies.
"RBRVS," see resource based relative value scale.
"RBRVS RVU" - 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.
"Reimbursement" - Payment to a provider or other agency-approved entity who bills according to the provisions in WAC 182-502-0100.
"Reimbursement steering committee (RSC)" - An interagency work group that establishes and maintains RBRVS physician fee schedules and other payment and purchasing systems utilized by the agency and the department of labor and industries.
"Relative value guide (RVG)" - A system used by the American Society of Anesthesiologists for determining base anesthesia units (BAUs).
"Relative value unit (RVU)" - A unit that is based on the resources required to perform an individual service or intervention.
"Resource based relative value scale (RBRVS)" - A scale that measures the relative value of a medical service or intervention, based on the amount of physician resources involved.
"RSC RVU" - 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.
"RVU," see relative value unit.
"Stat laboratory charges" - Charges by a laboratory for performing tests immediately. "Stat" is an abbreviation for the Latin word "statim," meaning immediately.
"Sterile tray" - 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 CMS to be nonroutine and reimbursed separately.
"Technical advisory group (TAG)" - 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 agency and the department of labor and industries.
"Technical component" - 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.
[Statutory Authority: RCW 41.05.021, 41.05.160, and 2018 c 299. WSR 19-09-052, § 182-531-0050, filed 4/12/19, effective 5/13/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-21-040, § 182-531-0050, filed 10/12/17, effective 11/12/17; WSR 17-09-002, § 182-531-0050, filed 4/5/17, effective 5/6/17; WSR 16-01-039, § 182-531-0050, filed 12/9/15, effective 1/9/16. Statutory Authority: RCW 41.05.021. WSR 12-16-061, § 182-531-0050, filed 7/30/12, effective 11/1/12. WSR 11-14-075, recodified as § 182-531-0050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0050, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 04-20-059, § 388-531-0050, filed 10/1/04, effective 11/1/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. WSR 03-19-081, § 388-531-0050, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090. WSR 03-06-049, § 388-531-0050, filed 2/28/03, effective 3/31/03. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0050, filed 12/6/00, effective 1/6/01.]



182-531-0100
Scope of coverage for physician-related and health care professional servicesGeneral and administrative.

(1) The medicaid agency covers health care services, equipment, and supplies listed in this chapter, according to agency rules and subject to the limitations and requirements in this chapter, when they are:
(a) Within the scope of an eligible client's Washington apple health program. Refer to WAC 182-501-0060 and 182-501-0065; and
(b) Medically necessary as defined in WAC 182-500-0070.
(2) The agency evaluates a request for a service that is in a covered category under the provisions of WAC 182-501-0165.
(3) The agency evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions as described in WAC 182-501-0169.
(4) The agency covers the following physician-related services and health care professional services, subject to the conditions in subsections (1), (2), and (3) of this section:
(a) Alcohol and substance misuse counseling (refer to WAC 182-531-1710);
(b) Allergen immunotherapy services;
(c) Anesthesia services;
(d) Dialysis and end stage renal disease services (refer to chapter 182-540 WAC);
(e) Emergency physician services;
(f) ENT (ear, nose, and throat) related services;
(g) Early and periodic screening, diagnosis, and treatment (EPSDT) services (refer to WAC 182-534-0100);
(h) Habilitative services (refer to WAC 182-545-400);
(i) Reproductive health services (refer to chapter 182-532 WAC);
(j) Hospital inpatient services (refer to chapter 182-550 WAC);
(k) Maternity care, delivery, and newborn care services (refer to chapter 182-533 WAC);
(l) Office visits;
(m) Vision-related services (refer to chapter 182-544 WAC for vision hardware for clients twenty years of age and younger);
(n) Osteopathic treatment services;
(o) Pathology and laboratory services;
(p) Physiatry and other rehabilitation services (refer to chapter 182-550 WAC);
(q) Foot care and podiatry services (refer to WAC 182-531-1300);
(r) Primary care services;
(s) Psychiatric services;
(t) Psychotherapy services (refer to WAC 182-531-1400);
(u) Pulmonary and respiratory services;
(v) Radiology services;
(w) Surgical services;
(x) Cosmetic, reconstructive, or plastic surgery, and related services and supplies to correct physiological defects (e.g., congenital or as a result of illness or physical trauma), or for mastectomy reconstruction for post cancer treatment;
(y) Telemedicine (refer to WAC 182-531-1730);
(z) Tobacco cessation counseling (refer to WAC 182-531-1720);
(aa) Vaccines for adults, adolescents, and children in the United States administered according to the current advisory committee on immunization practices (ACIP) recommended immunization schedule published by the Centers for Disease Control and Prevention (CDC). Vaccines outside the regular schedule may be covered if determined to be medically necessary;
(bb) Other outpatient physician services.
(5) The agency covers physical examinations for Washington apple health clients only when the physical examination is for one or more of the following:
(a) A screening exam covered by the EPSDT program (see WAC 182-534-0100);
(b) An annual exam for clients of the division of developmental disabilities; or
(c) A screening pap smear, mammogram, or prostate exam.
(6) By providing covered services to a client eligible for Washington apple health, a provider who meets the requirements in WAC 182-502-0005(3) accepts the agency's rules and fees which includes federal and state law and regulations, billing instructions, and provider notices.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-21-058, § 182-531-0100, filed 10/9/18, effective 11/9/18; WSR 15-03-041, § 182-531-0100, filed 1/12/15, effective 2/12/15. Statutory Authority: RCW 41.05.021. WSR 13-18-035, § 182-531-0100, filed 8/28/13, effective 9/28/13. Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455.410. WSR 13-04-095, § 182-531-0100, filed 2/6/13, effective 3/9/13. Statutory Authority: RCW 41.05.021 and section 1927 of the Social Security Act. WSR 12-18-062, § 182-531-0100, filed 8/31/12, effective 10/1/12. WSR 11-14-075, recodified as § 182-531-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-0100, filed 6/29/11, effective 7/30/11. Statutory Authority: RCW 74.09.521. WSR 08-12-030, § 388-531-0100, filed 5/29/08, effective 7/1/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-531-0100, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0100, filed 12/6/00, effective 1/6/01.]



182-531-0150
Noncovered physician-related and health care professional servicesGeneral and administrative.

(1) The medicaid agency evaluates a request for noncovered services in this chapter under WAC 182-501-0160. In addition to noncovered services found in WAC 182-501-0070, except as provided in subsection (2) of this section, the agency does not cover:
(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) Hysterectomy performed solely for the purpose of sterilization;
(e) Cosmetic treatment or surgery, except as provided in WAC 182-531-0100 (4)(x);
(f) 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 182-501-0165;
(g) Hair transplantation;
(h) Marital counseling or sex therapy;
(i) More costly services when the medicaid agency determines that less costly, equally effective services are available;
(j) Vision-related services as follows:
(i) Services for cosmetic purposes only;
(ii) Group vision screening for eyeglasses; and
(iii) Refractive surgery of any type that changes the eye's refractive error. The intent of the refractive surgery procedure is to reduce or eliminate the need for eyeglass or contact lens correction. This refractive surgery does not include intraocular lens implantation following cataract surgery.
(k) Payment for body parts, including organs, tissues, bones and blood, except as allowed in WAC 182-531-1750;
(l) Physician-supplied medication, except those drugs which the client cannot self-administer and therefore are administered by the physician in the physician's office;
(m) Physical examinations or routine checkups, except as provided in WAC 182-531-0100;
(n) Foot care, unless the client meets criteria and conditions outlined in WAC 182-531-1300, as follows:
(i) Routine foot care including, but not limited to:
(A) Treatment of tinea pedis;
(B) Cutting or removing warts, corns and calluses; and
(C) Trimming, cutting, clipping, or debriding of nails.
(ii) Nonroutine foot care including, but not limited to, treatment of:
(A) Flat feet;
(B) High arches (cavus foot);
(C) Onychomycosis;
(D) Bunions and tailor's bunion (hallux valgus);
(E) Hallux malleus;
(F) Equinus deformity of foot, acquired;
(G) Cavovarus deformity, acquired;
(H) Adult acquired flatfoot (metatarsus adductus or pes planus);
(I) Hallux limitus.
(iii) Any other service performed in the absence of localized illness, injury, or symptoms involving the foot;
(o) Except as provided in WAC 182-531-1600, weight reduction and control services, procedures, treatments, devices, drugs, products, gym memberships, equipment for the purpose of weight reduction, or the application of associated services;
(p) Nonmedical equipment;
(q) Nonemergent admissions and associated services to out-of-state hospitals or noncontracted hospitals in contract areas;
(r) Vaccines recommended or required for the sole purpose of international travel. This does not include routine vaccines administered according to current centers for disease control (CDC) advisory committee on immunization practices (ACIP) immunization schedule for adults and children in the United States; and
(s) Early elective deliveries as defined in WAC 182-500-0030.
(2) The medicaid agency 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 Washington apple health program for qualified medicare beneficiaries (QMBs); or
(c) A waiver program.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-021, § 182-531-0150, filed 11/19/15, effective 1/1/16; WSR 15-03-041, § 182-531-0150, filed 1/12/15, effective 2/12/15. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-531-0150, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-531-0150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-0150, filed 6/29/11, effective 7/30/11; WSR 10-19-057, § 388-531-0150, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-12-022, § 388-531-0150, filed 5/20/05, effective 6/20/05; WSR 01-01-012, § 388-531-0150, filed 12/6/00, effective 1/6/01.]



182-531-0200
Physician-related and health care professional services requiring prior authorization.

(1) The medicaid agency requires prior authorization for certain services. Prior authorization includes expedited prior authorization (EPA) and limitation extension (LE). See WAC 182-501-0165.
(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 the medicaid agency's physician-related billing instructions.
(b) Upon request, the provider must provide supporting clinical documentation to the medicaid agency showing how the authorization number was created.
(c) Selected nonemergency admissions to contract hospitals require EPA. These are identified in the medicaid agency billing instructions.
(d) Procedures allowing expedited prior authorization include, but are not limited to, the following:
(i) Reduction mammoplasties/mastectomy for gynecomastia;
(ii) Strabismus surgery for clients eighteen years of age and older;
(iii) Meningococcal vaccine;
(iv) Placement of drug eluting stent and device;
(v) Cochlear implants for clients twenty years of age and younger;
(vi) Hyperbaric oxygen therapy;
(vii) Visual exam/refraction for clients twenty-one years of age and older;
(viii) Blepharoplasties; and
(ix) Neuropsychological testing for clients sixteen years of age and older.
(3) The medicaid agency evaluates new technologies under the procedures in WAC 182-531-0550. 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) Unilateral cochlear implants for clients twenty years of age and younger (refer to WAC 182-531-0375);
(d) Diagnosis and treatment of eating disorders for clients twenty-one years of age and older;
(e) Osteopathic manipulative therapy in excess of the medicaid agency's published limits;
(f) Panniculectomy;
(g) Bariatric surgery (see WAC 182-531-1600);
(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.
(i) Osseointegrated/bone anchored hearing aids (BAHA) for clients twenty years of age and younger;
(j) Removal or repair of previously implanted BAHA or cochlear device for clients twenty one years of age and older when medically necessary; and
(k) Gender reassignment surgery (see WAC 182-531-1675).
(5) All hysterectomies performed for medical reasons may require prior authorization, as explained in subsection (2) of this section.
(a) Hysterectomies may be performed without prior authorization in either of the following circumstances:
(i) The client has been diagnosed with cancer(s) of the female reproductive organs; and/or
(ii) A hysterectomy is needed due to trauma.
(b) The agency reimburses all attending providers for a hysterectomy procedure only when the provider submits an accurately completed agency-approved consent form with the claim for reimbursement.
(6) The medicaid agency may require a second opinion and/or consultation before authorizing any elective surgical procedure.
(7) Children six years of age and younger do not require authorization for hospitalization.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 15-16-084, § 182-531-0200, filed 7/31/15, effective 8/31/15. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-531-0200, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-531-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-0200, filed 6/29/11, effective 7/30/11; WSR 10-19-057, § 388-531-0200, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-12-022, § 388-531-0200, filed 5/20/05, effective 6/20/05; WSR 01-01-012, § 388-531-0200, filed 12/6/00, effective 1/6/01.]



182-531-0250
Who can provide and bill for physician-related and health care professional services.

(1) The health care professionals and health care entities listed in WAC 182-502-0002 and enrolled with the medicaid agency can bill for physician-related and health care professional services that are within their scope of practice.
(2) The agency pays for services provided by, or in conjunction with, a resident physician when:
(a) The services are billed under the teaching hospital's national provider identifier (NPI) or the supervising physician's NPI;
(b) The performing provider is identified on the claim under the teaching or resident physician's NPI; and
(c) The services are provided and billed according to this chapter and chapters 182-501 and 182-502 WAC.
(3) The agency does not pay for services performed by any of the health care professionals listed in WAC 182-502-0003.
(4) The agency pays eligible providers for physician-related services and health care professional services if those services are mandated by, and provided to clients who are eligible for, one of the following:
(a) The early and periodic screening, diagnosis, and treatment (EPSDT) program;
(b) A Washington apple health program for qualified medicare beneficiaries (QMB); or
(c) A waiver program.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-066, § 182-531-0250, filed 8/14/15, effective 9/14/15; WSR 15-03-041, § 182-531-0250, filed 1/12/15, effective 2/12/15. WSR 11-14-075, recodified as § 182-531-0250, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-0250, filed 6/29/11, effective 7/30/11. Statutory Authority: RCW 74.09.521. WSR 08-12-030, § 388-531-0250, filed 5/29/08, effective 7/1/08. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-12-022, § 388-531-0250, filed 5/20/05, effective 6/20/05; WSR 01-01-012, § 388-531-0250, filed 12/6/00, effective 1/6/01.]



182-531-0300
Anesthesia providers and covered physician-related services.

The medicaid agency bases coverage of anesthesia services on medicare policies and the following rules:
(1) The agency reimburses providers for covered anesthesia services performed by:
(a) Anesthesiologists;
(b) Certified registered nurse anesthetists (CRNAs);
(c) Oral surgeons with a special agreement with the agency to provide anesthesia services; and
(d) Other providers who have a special agreement with the agency to provide anesthesia services.
(2) The agency 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) The agency 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 182-531-1550 for information about sterilization/hysterectomy anesthesia;
(c) Pain management per subsection (5) of this section;
(d) Radiological services as listed in WAC 182-531-1450; and
(e) Surgical procedures.
(4) For each client, the anesthesiologist provider must do all of the following:
(a) Perform a preanesthetic 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) The agency does not allow the anesthesiologist 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) The agency 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, the agency reimburses the base anesthesia units (BAU) for the major procedure only.
(b) The agency does not reimburse the attending surgeon for anesthesia services.
(c) When more than one anesthesia provider is present on a case, the agency 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, the agency limits reimbursement to one hundred percent of the total allowed reimbursement for the service.
(8) Pain management:
(a) The agency pays CRNAs or anesthesiologists for pain management services.
(b) The agency 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) The agency does not apply the six-hour limit for anesthesia to procedures performed as a result of post-delivery complications.
(c) See WAC 182-531-1550 for information on anesthesia services during a delivery with sterilization.
(d) See chapter 182-533 WAC for more information about maternity-related services.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 17-04-039, § 182-531-0300, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-0300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0300, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0300, filed 12/6/00, effective 1/6/01.]



182-531-0350
Anesthesia services—Reimbursement for physician-related services.

(1) The department reimburses anesthesia services on the basis of base anesthesia units (BAU) plus time.
(2) The department 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) The department obtains BAU values from the relative value guide (RVG), and updates them annually. The department 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) The department 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) The department 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) The department 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 the department's annual update.
(7) If the legislatively authorized vendor rate increase or other increase becomes effective at the same time as the department's annual update, the department applies the increase after calculating the budget-neutral conversion factor.
(8) When more than one surgical procedure is performed at the same operative session, the department uses the BAU of the major procedure to determine anesthesia allowed charges. The department reimburses for 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.
[WSR 11-14-075, recodified as § 182-531-0350, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0350, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0350, filed 12/6/00, effective 1/6/01.]



182-531-0375
Audiology services.

(1) The agency covers, with prior authorization, cochlear devices for clients twenty years of age and younger with the following limitations:
(a) The client meets one of the following:
(i) Has a diagnosis of profound to severe bilateral, sensorineural hearing loss;
(ii) Has stimulable auditory nerves but has limited benefit from appropriately fitted hearing aids (e.g., fail to meet age-appropriate auditory milestones in the best-aided condition for young children, or score of less than ten or equal to forty percent correct in the best-aided condition on recorded open-set sentence recognition tests);
(iii) Has the cognitive ability to use auditory clues;
(iv) Is willing to undergo an extensive rehabilitation program;
(v) Has an accessible cochlear lumen that is structurally suitable for cochlear implantation;
(vi) Does not have lesions in the auditory nerve and/or acoustic areas of the central nervous system; or
(vii) Has no other contraindications to surgery; and
(b) The procedure is performed in an inpatient hospital setting or outpatient hospital setting.
(2) The agency covers BAHAs for clients twenty years of age and younger with prior authorization.
(3) The agency covers replacement parts and batteries for BAHAs and cochlear devices for clients twenty years of age and younger only. See WAC 182-547-0800.
(4) The agency considers requests for removal or repair of previously implanted BAHAs and cochlear devices for clients twenty one years of age and older only when medically necessary. Prior authorization from the agency is required.
(5) For audiology, the agency limits:
(a) Caloric vestibular testing to four units for each ear; and
(b) Sinusoidal vertical axis rotational testing to three units for each direction.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 15-03-042, § 182-531-0375, filed 1/12/15, effective 2/12/15. WSR 11-14-075, recodified as § 182-531-0375, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-0375, filed 6/29/11, effective 7/30/11.]



182-531-0400
Client responsibility for reimbursement for physician-related services.

Clients may be responsible to reimburse the provider, as described under WAC 182-501-0100, for noncovered services as defined in WAC 182-501-0050 or for services excluded from the client's benefits package as defined under WAC 182-501-0060. Clients whose care is provided under CHIP may be responsible for copayments as outlined in chapter 182-542 WAC. Also, see WAC 182-502-0160 Billing the client.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 17-04-039, § 182-531-0400, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-0400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-0400, filed 6/29/11, effective 7/30/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0400, filed 12/6/00, effective 1/6/01.]



182-531-0425
Collaborative care.

(1) Under the authority of RCW 74.09.497, and subject to available funds, the medicaid agency covers collaborative care provided in clinical care settings.
(2) For the purposes of this section:
(a) Collaborative care means a specific type of integrated care where medical providers and behavioral health providers work together to address behavioral health conditions, including mental health conditions and substance use disorders.
(b) Collaborative care model is a model of behavior health integration that enhances usual clinical care by adding two key services:
(i) Care management support for clients receiving behavioral health treatment; and
(ii) Regular psychiatric or board certified addiction medicine consultation with the clinical care team, particularly for clients whose conditions are not improving.
(c) Collaborative care team means a team of licensed behavioral health professionals operating within their scope of practice who participate on the clinical care team along with the collaborative care billing provider to provide collaborative care to eligible clients. The team must include a collaborative care billing provider, a behavioral health care manager, and a psychiatric consultant. Professionals making up this team include, but are not limited to:
(i) Advanced registered nurses;
(ii) Chemical dependency professionals;
(iii) Chemical dependency professional trainees under the supervision of a certified chemical dependency professional;
(iv) Marriage and family therapists;
(v) Marriage and family therapist associates under the supervision of a licensed marriage and family therapist or equally qualified mental health practitioner;
(vi) Mental health counselors;
(vii) Mental health counselor associates under the supervision of a licensed mental health counselor, psychiatrist, or physician;
(viii) Physicians;
(ix) Physician assistants under the supervision of a licensed physician;
(x) Psychiatrists;
(xi) Psychiatric advanced registered nurses;
(xii) Psychologists;
(xiii) Registered nurses;
(xiv) Social workers;
(xv) Social worker associate-independent clinical, under the supervision of a licensed independent clinical social worker or equally qualified mental health practitioner; and
(xvi) Social worker associate-advanced, under the supervision of a licensed independent clinical social worker, advanced social worker, or equally qualified mental health practitioner.
(3) The behavioral health care manager is a designated licensed professional with formal education or specialized training in behavioral health (including social work, nursing, or psychology), working under the oversight and direction of the treating medical provider.
(4) The collaborative care billing provider must meet all of the following:
(a) Be enrolled with the agency as one of the following:
(i) A physician licensed under Titles 18 RCW and 246 WAC;
(ii) An advanced registered nurse practitioner licensed under Titles 18 RCW and 246 WAC;
(iii) A federally qualified health center (FQHC);
(iv) A rural health clinic (RHC); or
(v) A clinic that is not an FQHC or RHC that meets the requirements of Titles 70 RCW and 247 WAC.
(b) Complete, sign, and return the Attestation for Collaborative Care Model, form HCA 13-0017, to the agency; and
(c) Agree to follow the agency's guidelines for practicing a collaborative care model.
(5) Providers of collaborative care must:
(a) Use a registry to track the client's clinical outcomes;
(b) Use at least one validated clinical rating scale;
(c) Ensure the registry is used in conjunction with the practice's electronic health records (EHR);
(d) Include a plan of care; and
(e) Identify outcome goals of the treatments.
(6) If a provider no longer meets the agreed upon requirements in the agency's Attestation for Collaborative Care Model, form HCA 13-0017, the provider must immediately notify the agency. The agency does not pay for collaborative care if a provider does not meet the agreed upon requirements.
(7) Providers are subject to post pay review by the agency. The agency may recoup payment if the provider is found to have not met the requirements for providing collaborative care as agreed to in the agency's Attestation for Collaborative Care Model, form HCA 13-0017.
[Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 c 226. WSR 19-13-022, § 182-531-0425, filed 6/10/19, effective 7/11/19.]



182-531-0450
Critical care—Physician-related services.

(1) The department 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) The department 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 bedside 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 the department.
(3) The department limits payment for critical care services to a maximum of three hours per day, per client.
(4) The department 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.
[WSR 11-14-075, recodified as § 182-531-0450, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0450, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0450, filed 12/6/00, effective 1/6/01.]



182-531-0500
Emergency physician-related services.

(1) The department reimburses for E&M services provided in the hospital emergency department to clients who arrive for immediate medical attention.
(2) The department 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) The department pays a provider who is called back to the emergency room at a different time on the same day to attend a return visit [to] 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) The department does not pay emergency room physicians for hospital admission charges or additional service charges.
[WSR 11-14-075, recodified as § 182-531-0500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0500, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0500, filed 12/6/00, effective 1/6/01.]



182-531-0550
Experimental and investigational services.

(1) When the medicaid agency determines a proposed service is experimental or investigational, the agency follows the procedures in this section.
(2) The determination of whether to authorize an experimental or investigational service is subject to a medical necessity review under the provisions of WAC 182-501-0165.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-09-002, § 182-531-0550, filed 4/5/17, effective 5/6/17. WSR 11-14-075, recodified as § 182-531-0550, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0550, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0550, filed 12/6/00, effective 1/6/01.]



182-531-0600
HIV/AIDS counseling and testing as physician-related services.

The department covers one pre- and one post-HIV/AIDS counseling/testing session per client each time the client is tested for HIV/AIDS.
[WSR 11-14-075, recodified as § 182-531-0600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0600, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0600, filed 12/6/00, effective 1/6/01.]



182-531-0650
Hospital physician-related services not requiring authorization when provided in agency-approved centers of excellence or hospitals authorized to provide the specific services.

The medicaid agency covers the following services without prior authorization when provided in agency-approved centers of excellence. The agency issues periodic publications listing centers of excellence. These services include the following:
(1) All transplant procedures specified in WAC 182-550-1900;
(2) Chronic pain management services, including outpatient evaluation and inpatient treatment, as described under WAC 182-550-2400. See also WAC 182-531-0700;
(3) Sleep studies including, but not limited to, polysomnograms for clients one year of age and older. The agency allows sleep studies only in outpatient hospital settings as described under WAC 182-550-6350. See also WAC 182-531-1500; and
(4) Diabetes education, in a DOH-approved facility, per WAC 182-550-6300.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 17-04-039, § 182-531-0650, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-0650, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0650, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-12-022, § 388-531-0650, filed 5/20/05, effective 6/20/05; WSR 01-01-012, § 388-531-0650, filed 12/6/00, effective 1/6/01.]



182-531-0700
Inpatient chronic pain management physician-related services.

(l) The department covers inpatient chronic pain management services only when the services are obtained through a department-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, the department limits coverage to only one inpatient hospital stay per client's lifetime, up to a maximum of twenty-one days.
(4) The department reimburses for only the chronic pain management services and procedures that are listed in the fee schedule.
[WSR 11-14-075, recodified as § 182-531-0700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0700, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0700, filed 12/6/00, effective 1/6/01.]



182-531-0750
Inpatient hospital physician-related services.

(1) The department 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) The department 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, the department does not reimburse separately.
(3) The department reimburses a hospital admission related to a planned surgery through the global fee for surgery.
[WSR 11-14-075, recodified as § 182-531-0750, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0750, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0750, filed 12/6/00, effective 1/6/01.]



182-531-0800
Laboratory and pathology physician-related services.

(1) The medicaid agency pays providers for laboratory services only when:
(a) The provider is certified according to Title XVII of the Social Security Act (medicare), if required; and
(b) The provider has a clinical laboratory improvement amendment (CLIA) certificate and identification number.
(2) The agency includes a handling, packaging, and mailing fee in the reimbursement for lab tests and does not reimburse these separately.
(3) The agency pays for one blood drawing fee per client, per day. The agency allows additional reimbursement for an independent laboratory when it goes to a nursing facility or a private home to obtain a specimen.
(4) The agency pays for only one catheterization for collection of a urine specimen per client, per day.
(5) The agency pays for 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, the agency 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) The agency allows a STAT fee in addition to the maximum allowable fee when a laboratory procedure is performed STAT.
(a) The agency pays for 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) The agency pays for drug screen charges only when medically necessary and when ordered by a physician as part of a total medical evaluation.
(8) The agency does not pay for drug screens for clients in the division of behavioral health and recovery (DBHR) within the department of social and health services (DSHS)-contracted methadone treatment programs. These are reimbursed through a contract issued by DBHR DSHS.
(9) The agency does not pay for drug screens to monitor for program compliance in either a residential or outpatient drug or alcohol treatment program.
(10) The agency may require a drug or alcohol screen in order to determine a client's suitability for a specific test.
(11) An independent laboratory must bill the agency directly. The agency does not pay a medical practitioner for services referred to or performed by an independent laboratory.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 15-03-041, § 182-531-0800, filed 1/12/15, effective 2/12/15. WSR 11-14-075, recodified as § 182-531-0800, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0800, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0800, filed 12/6/00, effective 1/6/01.]



182-531-0850
Laboratory and pathology physician-related services reimbursement.

(1) The department pays for clinical diagnostic laboratory procedures based on the medicare clinical diagnostic laboratory fee schedule (MCDLF) for the state of Washington. The department obtains information used to update fee schedule regulations from Program Memorandum and Regional Medicare Letters as published by HCFA.
(2) The department 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 department fees to existing medicare fees. Then,
(c) Determining new department fees by adjusting the new medicare fee by the ratio. Then,
(d) Multiplying the units of service by the new department 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) The department 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. The department updates flat fee reimbursement only when authorized by the legislature.
(d) The department reimbursement for clinical laboratory diagnostic procedures does not exceed the regional MCDLF schedule.
(4) The department 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 the department's annual update, the department applies the increase after calculating budget-neutral fees.
[WSR 11-14-075, recodified as § 182-531-0850, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0850, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0850, filed 12/6/00, effective 1/6/01.]



182-531-0900
Neonatal intensive care unit (NICU) physician-related services.

(1) The department 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) The department 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.
[WSR 11-14-075, recodified as § 182-531-0900, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0900, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0900, filed 12/6/00, effective 1/6/01.]



182-531-0950
Office and other outpatient physician-related services.

(l) The medicaid agency pays eligible providers for the following:
(a) Two calls per month for routine medical conditions for a client residing in a nursing facility; and
(b) One call per noninstitutionalized client, per day, for an individual physician, except for valid call-backs to the emergency room per WAC 182-531-0500.
(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 and follow the requirements in WAC 182-501-0169.
(3) See the agency's physician-related services billing instructions for procedures that are included in the office call and that cannot be billed separately.
(4) Using selected diagnosis codes, the agency 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) The agency 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 which was purchased by the provider from a pharmacy, drug manufacturer, or drug wholesaler.
(6) The agency does not reimburse a prescribing provider for a drug when a pharmacist dispenses the drug.
(7) The agency does not reimburse the prescribing provider for an immunization when the immunization material is received from the department of health; the agency does reimburse an administrative fee.
(8) The agency reimburses immunizations as follows:
(a) For immunizations that are not part of the vaccines for children program through the department of health, the agency reimburses for the immunization:
(i) At the medicare Part B drug file price; or
(ii) When a medicare Part B price is not available, the agency uses the point-of-sale actual acquisition cost (POS AAC) rate effective July 1st of each year; or
(iii) Invoice cost.
(b) The agency reimburses a separate administration fee for these immunizations.
(c) Covered immunizations are listed in the professional administered drugs and physician related/professional services fee schedules.
(d) Refer to WAC 182-531-0150 (1)(r) for vaccines recommended or required for the sole purpose of international travel.
(9) The agency reimburses therapeutic and diagnostic injections subject to certain limitations as follows:
(a) The agency does not pay separately for the administration of intra-arterial and intravenous therapeutic or diagnostic injections provided in conjunction with intravenous infusion therapy services. The agency does pay separately for the administration of these injections when they are provided on the same day as an E&M service. The agency does not pay separately an administrative fee for injectables when both E&M and infusion therapy services are provided on the same day. The agency reimburses separately for the drug(s).
(b) The agency does not pay separately for subcutaneous or intramuscular administration of antibiotic injections provided on the same day as an E&M service. If the injection is the only service provided, the agency pays an administrative fee. The agency reimburses separately for the drug.
(c) The agency 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 the agency. 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 to document the name, strength, and dosage on the claim form when billing the agency for the following drugs:
(i) Classified drugs where the billed charge to the agency is over one thousand, one hundred dollars; and
(ii) Unclassified drugs where the billed charge to the agency is over one hundred dollars. This does not apply to unclassified antineoplastic drugs.
(10) The agency reimburses allergen immunotherapy only as follows:
(a) Antigen/antigen preparation codes are reimbursed per dose.
(b) When a single client is expected to use all the doses in a multiple dose vial, the provider may bill the total number of doses in the vial at the time the first dose from the vial is used. When remaining doses of a multiple dose vial are injected at subsequent times, the agency reimburses the injection service (administration fee) only.
(c) When a multiple dose vial is used for more than one client, the provider must bill the total number of doses provided to each client out of the multiple dose vial.
(d) The agency covers the antigen, the antigen preparation, and an administration fee.
(e) The agency reimburses a provider separately for an E&M service if there is a diagnosis for conditions unrelated to allergen immunotherapy.
(f) The agency 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) The agency reimburses for chemotherapy drugs:
(a) 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) At established maximum allowable fees that are based on medicare Part B pricing, or POS AAC, maximum allowable cost (MAC), or invoice cost;
(c) For unclassified antineoplastic drugs, the provider must submit the following information on the claim form:
(i) The name of the drug used;
(ii) The dosage and strength used; and
(iii) The National Drug Code (NDC).
(12) Notwithstanding the provisions of this section, the agency reserves the option of determining drug pricing for any particular drug based on the best evidence available to the agency, or other good and sufficient reasons (e.g., fairness/equity, budget), regarding the actual cost, after discounts and promotions, paid by typical providers nationally or in Washington state.
(13) The agency may request an invoice as necessary.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-21-040, § 182-531-0950, filed 10/12/17, effective 11/12/17; WSR 15-20-057, § 182-531-0950, filed 10/1/15, effective 11/1/15; WSR 15-03-041, § 182-531-0950, filed 1/12/15, effective 2/12/15. WSR 11-14-075, recodified as § 182-531-0950, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0950, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0950, filed 12/6/00, effective 1/6/01.]



182-531-1000
Ophthalmic services.

Refer to chapter 182-544 WAC for vision-related hardware coverage.
(1) The medicaid agency covers eye examinations, refraction and fitting services. The agency pays for these services without prior authorization as follows:
(a) Once every twenty-four months for asymptomatic clients age twenty-one and older;
(b) Once every twelve months for asymptomatic clients age twenty and younger; or
(c) Once every twelve months, regardless of age, for asymptomatic clients of the division of developmental disabilities.
(2) The agency covers additional eye examinations and refraction services when:
(a) The provider is diagnosing or treating the client for a medical condition that has symptoms of vision problems or disease;
(b) The client is on medication that affects vision; or
(c) An eye examination or refraction is necessary due to lost or broken eyeglasses or contacts. In this case:
(i) No type of authorization is required for clients age twenty or younger or for clients of the division of developmental disabilities, regardless of age.
(ii) Providers must follow the agency's expedited prior authorization process to receive payment for clients age twenty-one or older. Providers must also document the following in the client's file:
(A) The eyeglasses or contacts are lost or broken; and
(B) The last examination was at least eighteen months ago.
(3) The agency covers visual field exams for the diagnosis and treatment of abnormal signs, symptoms, or injuries. Providers must document all of the following in the client's record:
(a) The extent of the testing;
(b) Why the testing was reasonable and necessary for the client; and
(c) The medical basis for the frequency of testing.
(4) The agency covers orthoptics and vision training therapy. Providers must obtain prior authorization from the agency.
(5) The agency covers ocular prosthetics for clients when provided by any of the following:
(a) An ophthalmologist;
(b) An ocularist; or
(c) An optometrist who specializes in prosthetics.
(6) The agency covers cataract surgery, without prior authorization when the following clinical criteria are met:
(a) Correctable visual acuity in the affected eye at 20/50 or worse, as measured on the Snellen test chart; or
(b) One or more of the following conditions:
(i) Dislocated or subluxated lens;
(ii) Intraocular foreign body;
(iii) Ocular trauma;
(iv) Phacogenic glaucoma;
(v) Phacogenic uveitis;
(vi) Phacoanaphylactic endopthalmitis; or
(vii) Increased ocular pressure in a person who is blind and is experiencing ocular pain.
(7) The agency covers strabismus surgery as follows:
(a) For clients age seventeen and younger. The provider must clearly document the need in the client's record. The agency does not require authorization for clients age seventeen and younger; and
(b) For clients age eighteen and older, when the clinical criteria are met. To receive payment, providers must follow the expedited prior authorization process. The clinical criteria are:
(i) The client has double vision; and
(ii) The surgery is not being performed for cosmetic reasons.
(8) The agency covers blepharoplasty or blepharoptosis surgery for clients when all of the clinical criteria are met. To receive payment, providers must follow the agency's expedited prior authorization process. The clinical criteria are:
(a) The client's excess upper eyelid skin is blocking the superior visual field; and
(b) The blocked vision is within ten degrees of central fixation using a central visual field test.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 17-14-067, § 182-531-1000, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-531-1000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-1000, filed 6/29/11, effective 7/30/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1000, filed 12/6/00, effective 1/6/01.]



182-531-1050
Manipulative therapy.

(1) The medicaid agency pays for manipulative therapy only when:
(a) Provided by an osteopathic physician licensed under chapter 18.57 RCW or naturopathic physicians licensed under chapter 18.36A RCW; and
(b) Billed using the appropriate CPT codes that involve the number of body regions involved.
(2) The agency allows an osteopathic physician or naturopathic physician to bill the agency for an evaluation and management (E&M) service in addition to the manipulative therapy 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.
(3) The agency pays for ten manipulations per client, per calendar year. The agency evaluates a request for manipulations that is in excess of the limitations or restrictions according to WAC 182-501-0169. Payment for each manipulation includes a brief evaluation as well as the manipulation.
(4) The agency does not pay for physical therapy services performed by osteopathic physicians or naturopathic physicians.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 15-03-041, § 182-531-1050, filed 1/12/15, effective 2/12/15. WSR 11-14-075, recodified as § 182-531-1050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1050, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1050, filed 12/6/00, effective 1/6/01.]



182-531-1100
Out-of-state physician services.

(1) The medicaid agency covers medical services provided to eligible clients who are temporarily located outside the state, subject to the provisions of this chapter and WAC 182-501-0180.
(2) Out-of-state border areas as described under WAC 182-501-0175 are not subject to out-of-state limitations. The agency 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.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 17-04-039, § 182-531-1100, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-1100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1100, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1100, filed 12/6/00, effective 1/6/01.]



182-531-1150
Physician care plan oversight services.

(1) The department 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) The department 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) The department reimburses only one physician per client, per month, for physician care plan oversight services.
(4) The department reimburses for physician care plan oversight services during the global surgical reimbursement period only when the care plan oversight is unrelated to the surgery.
[WSR 11-14-075, recodified as § 182-531-1150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1150, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1150, filed 12/6/00, effective 1/6/01.]



182-531-1200
Physician office medical supplies.

(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 the department considers nonroutine to office or outpatient procedures.
(2) The department 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 the department upon request.
(3) Providers must submit invoices for items costing fifty dollars or more.
(4) The department reimburses for sterile tray for certain surgical services only. Refer to the fee schedule for a list of covered items.
[WSR 11-14-075, recodified as § 182-531-1200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1200, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1200, filed 12/6/00, effective 1/6/01.]



182-531-1250
Physician standby services.

(1) The department 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) The department 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. The department reimburses subsequent periods of physician standby service only when full thirty minutes of standby is provided for each unit billed. The department 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.
[WSR 11-14-075, recodified as § 182-531-1250, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1250, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1250, filed 12/6/00, effective 1/6/01.]



182-531-1300
Foot care services for clients twenty-one years of age and older.

(1) This section addresses care of the lower extremities (foot and ankle) referred to as foot care and applies to clients twenty-one years of age and older.
(2) The department covers the foot care services listed in this section when those services are provided by any of the following health care providers and billed to the department using procedure codes and diagnosis codes that are within their scope of practice:
(a) Physicians or physician's assistants-certified (PA-C);
(b) Osteopathic physicians, surgeons, or physician's assistant-certified (PA-C);
(c) Podiatric physicians and surgeons; or
(d) Advanced registered nurse practitioners (ARNP).
(3) The department covers evaluation and management visits to assess and diagnose conditions of the lower extremities. Once diagnosis is made, the department covers treatment if the criteria in subsection (4) of this section are met.
(4) The department pays for:
(a) Treatment of the following conditions of the lower extremities only when there is an acute condition, an exacerbation of a chronic condition, or presence of a systemic condition such as metabolic, neurologic, or peripheral vascular disease and evidence that the treatment will prevent, cure or alleviate a condition in the client that causes pain resulting in the inability to perform activities of daily living, acute disability, or threatens to cause the loss of life or limb, unless otherwise specified:
(i) Acute inflammatory processes such as, but not limited to tendonitis;
(ii) Circulatory compromise such as, but are not limited to:
(A) Lymphedema;
(B) Raynaud's disease;
(C) Thromboangiitis obliterans; and
(D) Phlebitis.
(iii) Injuries, fractures, sprains, and dislocations;
(iv) Gout;
(v) Lacerations, ulcerations, wounds, blisters;
(vi) Neuropathies (e.g., reflex sympathetic dystrophy, secondary to diabetes, charcot arthropathy);
(vii) Osteomyelitis;
(viii) Post-op complications;
(ix) Warts, corns, or calluses in the presence of an acute condition such as infection and pain effecting the client's ability to ambulate as a result of the warts, corns, or calluses and meets the criteria in subsection (4) of this section;
(x) Soft tissue conditions, such as, but are not limited to:
(A) Rashes;
(B) Infections (fungal, bacterial);
(C) Gangrene;
(D) Cellulitis of lower extremities;
(E) Soft tissue tumors; and
(F) Neuroma.
(xi) Nail bed infections (paronychia); and
(xii) Tarsal tunnel syndrome.
(b) Trimming and/or debridement of nails to treat, as applicable, conditions from the list in subsection (4)(a) of this section. The department pays for one treatment in a sixty-day period. The department covers additional treatments in this period if documented in the client's medical record as being medically necessary;
(c) A surgical procedure to treat one of the conditions in subsection (4) of this section performed on the lower extremities, and performed by a qualified provider;
(d) Impression casting to treat one of the conditions in subsection (4) of this section. The department includes ninety-day follow-up care in the reimbursement;
(e) Custom fitted and/or custom molded orthotic devices to treat one of the conditions in subsection (4) of this section.
(i) The department'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) The department includes an evaluation and management (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.
(5) The department does not pay for:
(a) The following radiology services:
(i) Bilateral X-rays for a unilateral condition; or
(ii) X-rays in excess of three views; or
(iii) X-rays that are ordered before the client is examined.
(b) Podiatric physicians or surgeons for X-rays for any part of the body other than the foot or ankle.
[WSR 11-14-075, recodified as § 182-531-1300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-1300, filed 6/29/11, effective 7/30/11; WSR 10-19-057, § 388-531-1300, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1300, filed 12/6/00, effective 1/6/01.]



182-531-1350
Prolonged physician-related service.

(1) The department 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) The department 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.
[WSR 11-14-075, recodified as § 182-531-1350, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1350, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1350, filed 12/6/00, effective 1/6/01.]



182-531-1400
Psychiatric physician-related services and other professional mental health services.

(1) The mental health services covered in this section are different from the mental health services covered under community mental health and involuntary treatment programs in chapter 182-538D WAC.
(2) Inpatient and outpatient mental health services not covered under chapter 182-538D WAC may be covered by the agency under this section.
Inpatient mental health services
(3) For hospital inpatient psychiatric admissions, providers must comply with chapter 182-538D WAC.
(4) The agency covers professional inpatient mental health services as follows:
(a) When provided by a psychiatrist, psychiatric advanced registered nurse practitioner (ARNP), psychiatric mental health nurse practitioner-board certified (PMHNP-BC), or psychologist in conjunction with the prescribing provider;
(b) The agency pays only for the total time spent on direct psychiatric client care during each visit, including services provided when making rounds. The agency considers services provided during rounds to be direct client care services and may include, but are not limited to:
(i) Individual psychotherapy up to one hour;
(ii) Family/group therapy; or
(iii) Electroconvulsive therapy.
(c) One electroconvulsive therapy or narcosynthesis per client, per day, and only when performed by a psychiatrist.
Outpatient mental health services
(5) The agency covers outpatient mental health services when provided by the following licensed health care professionals who are eligible providers under chapter 182-502 WAC:
(a) Psychiatrists;
(b) Psychologists;
(c) Psychiatric advanced registered nurse practitioners (ARNP);
(d) Psychiatric mental health nurse practitioners-board certified (PMHNP-BC);
(e) Mental health counselors;
(f) Independent clinical social workers;
(g) Advanced social workers; or
(h) Marriage and family therapists.
(6) With the exception of licensed psychiatrists and psychologists, qualified health care professionals who treat clients age eighteen and younger must:
(a) Have a minimum of one hundred actual hours of specialized study of child development and treatment and a minimum of one year of supervised experience in the diagnosis and treatment of clients age eighteen and younger; or
(b) Be working under supervision of a professional who meets these criteria.
(7) The agency does not limit the total number of outpatient mental health visits a licensed health care professional can provide.
(8) The agency evaluates a request for covered outpatient mental health services in excess of the limitations in this section under WAC 182-501-0169. The agency covers outpatient mental health services with the following limitations:
(a) One psychiatric diagnostic evaluation, per provider, per client, per calendar year, unless significant change in the client's circumstances renders an additional evaluation medically necessary and is authorized by the agency.
(b) One or more individual or family/group psychotherapy visits, with or without the client, per day, per client, when medically necessary.
(c) One psychiatric medication management service, per client, per day, in an outpatient setting when performed by one of the following:
(i) Psychiatrist;
(ii) Psychiatric advanced registered nurse practitioner (ARNP); or
(iii) Psychiatric mental health nurse practitioner-board certified (PMHNP-BC).
(9) To receive payment for providing mental health services, providers must bill the agency using the agency's published billing instructions.
[Statutory Authority: RCW 41.05.021, 41.05.16 [41.05.160], and 2017 c 226. WSR 19-15-107, § 182-531-1400, filed 7/22/19, effective 8/22/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 225. WSR 16-06-053, § 182-531-1400, filed 2/24/16, effective 4/1/16. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 15-03-041, § 182-531-1400, filed 1/12/15, effective 2/12/15. WSR 11-14-075, recodified as § 182-531-1400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.09.521. WSR 08-12-030, § 388-531-1400, filed 5/29/08, effective 7/1/08. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1400, filed 12/6/00, effective 1/6/01.]



182-531-1450
Radiology physician-related services.

(1) The medicaid agency reimburses radiology services subject to the limitations in this section and under WAC 182-531-0300.
(2) The agency 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) Preexisting 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) The agency reimburses separately for radiopharmaceutical diagnostic imaging agents for nuclear medicine procedures. Providers must submit invoices for these procedures when requested by the agency, and reimbursement is at acquisition cost.
(4) The agency reimburses general anesthesia for radiology procedures. See WAC 182-531-0300.
(5) The agency reimburses radiology procedures in combination with other procedures according to the rules for multiple surgeries. See WAC 182-531-1700. 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) The agency reimburses consultation on X-ray examinations. The consulting physician must bill the specific radiological X-ray code with the appropriate professional component modifier.
(7) The agency 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 contrast media;
(b) Diagnostic mammograms; and
(c) Skeletal films involving extremities, pelvis, vertebral column or skull.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 17-04-039, § 182-531-1450, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-1450, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1450, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1450, filed 12/6/00, effective 1/6/01.]



182-531-1500
Sleep studies.

(1) Purpose. For the purposes of this section, sleep studies include polysomnography (PSG), unattended home sleep test (HST), and multiple sleep latency testing (MSLT). The medicaid agency covers attended, full-channel, PSG, MSLT, and unattended HSTs when:
(a) Ordered by the client's physician;
(b) Performed by an agency-designated center of excellence (COE) that is an independent diagnostic testing facility, sleep laboratory, or outpatient hospital; and
(c) Results are used to:
(i) Establish a diagnosis of narcolepsy or sleep apnea; or
(ii) Evaluate a client's response to therapy, such as continuous positive airway pressure (CPAP).
(2) Definitions. The following definitions, those found in chapter 182-500 WAC, and definitions found in other sections of this chapter, apply to this section:
(a) "American Academy of Sleep Medicine" or "AASM" - The only professional society dedicated exclusively to the medical subspecialty of sleep medicine. AASM sets standards and promotes excellence in health care, education, and research. Members specialize in studying, diagnosing, and treating disorders of sleep and daytime alertness such as insomnia, narcolepsy, and obstructive sleep apnea.
(b) "Continuous positive airway pressure" or "CPAP" - See WAC 182-552-0005.
(c) "Core provider agreement" or "CPA" - The basic contract the agency holds with providers serving medical assistance clients.
(d) "Multiple sleep latency test" or "MSLT" - A sleep disorder diagnostic tool used to measure the time elapsed from the start of a daytime nap period to the first signs of sleep, called sleep latency. The MSLT is used extensively to test for narcolepsy, to distinguish between physical tiredness and true excessive daytime sleepiness, or to assess whether treatments for breathing disorders are working.
(e) "Obstructive sleep apnea" or "OSA" - See WAC 182-552-0005.
(f) "Polysomnogram" - The test results from a polysomnography.
(g) "Polysomnography" - A multiparametric test that electronically transmits and records specific physical activities while a person sleeps. The recordings become data that are analyzed by a qualified sleep specialist to determine whether or not a person has a sleep disorder.
(h) "PSG" - The abbreviation for both "polysomnography" and "polysomnogram."
(i) "Registered polysomnographic technologist" or "RPSGT" - A sleep technologist credentialed by the board of registered polysomnographic technologists to assist sleep specialists in the clinical assessment, physiological monitoring and testing, diagnosis, management, and prevention of sleep-related disorders with the use of various diagnostic and therapeutic tools. These tools include, but are not limited to, polysomnograph, positive airway pressure devices, oximeter, capnograph, actigraph, nocturnal oxygen, screening devices, and questionnaires. To become certified as a registered polysomnographic technologist, a sleep technologist must have the necessary clinical experience, hold CPR certification or its equivalent, adhere to the board of registered polysomnographic technologists standards of conduct, and pass the registered polysomnographic technologist examination for polysomnographic technologists.
(3) Client eligibility. Clients in the following agency programs are eligible to receive sleep studies as described in this section:
(a) Categorically needy (CN);
(b) Apple health for kids and other children's medical assistance programs as defined in WAC 182-505-0210;
(c) Medical care services as described in WAC 182-508-0005 (within Washington state or border areas only); and
(d) Medically needy (MN) only when the client is either:
(i) Twenty years of age or younger and referred by a screening provider under the early and periodic screening, diagnosis, and treatment program as described in chapter 182-534 WAC; or
(ii) Receiving home health care services as described in chapter 182-551 WAC, subchapter II.
(4) Provider requirements. To be paid for providing sleep studies as described in this section to eligible clients, the facility must:
(a) Be a sleep study COE. Refer to subsection (5) of this section for information on becoming an agency-approved sleep study COE;
(b) Be currently accredited by AASM and continuously meet the accreditation standards of AASM;
(c) Have at least one physician on staff who is board certified in sleep medicine; and
(d) Have at least one registered polysomnographic technologist (RPSGT) in the sleep lab when studies are being performed.
(5) Documentation.
(a) To become an agency-approved COE, a sleep center must send the following documentation to the Health Care Authority, c/o Provider Enrollment, P.O. Box 45510, Olympia, WA 98504-5510:
(i) A completed CPA; and
(ii) A copy of the sleep center's current accreditation certificate by AASM.
(b) Facilities accredited by the AASM must be in compliance with all accreditation standards at the time of application and throughout the accreditation period.
(c) Sleep centers must request reaccreditation from AASM in time to avoid expiration of COE status with the agency.
(d) At least one physician on staff at the sleep center must be board certified in sleep medicine. If the only physician on staff who is board certified in sleep medicine resigns, the sleep center must ensure another physician on staff at the sleep center obtains board certification or another board-certified physician is hired. The sleep center must then send provider enrollment a copy of the physician's board certification.
(e) If a certified medical director leaves a COE, the COE status does not transfer with the medical director to another sleep center.
(f) The COE must maintain a record of the physician's order for the sleep study.
(6) Coverage.
(a) The agency pays for only medically necessary sleep studies. The need for the sleep study must be confirmed by medical evidence (e.g., physician examination and laboratory tests).
(b) For clients age twenty-one and older, the agency covers:
(i) An unattended home sleep test (HST) as follows:
(A) Using one of the following HST devices:
(I) Type II home sleep monitoring device;
(II) Type III home sleep monitoring device; or
(III) Type IV home sleep monitoring device that measures at least three channels.
(B) To confirm obstructive sleep apnea (OSA) in an individual with signs or symptoms consistent with OSA (e.g., loud snoring, awakening with gasping or choking, excessive daytime sleepiness, observed cessation of breathing during sleep, etc.).
(ii) Full-night, in-laboratory PSG for either of the following:
(A) Confirmation of obstructive sleep apnea (OSA) in an individual with signs or symptoms consistent with OSA (e.g., loud snoring, awakening with gasping or choking, excessive daytime sleepiness, observed cessation of breathing during sleep, etc.); or
(B) Titration of positive airway pressure therapy when initial PSG confirms the diagnosis of OSA, and positive airway pressure is ordered; or
(iii) Split-night, in-laboratory PSG in which the initial diagnostic portion of the PSG is followed by positive airway pressure titration when the PSG meets either of the following criteria:
(A) The apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) is greater than or equal to fifteen events per hour; or
(B) The AHI or RDI is greater than or equal to five and less than or equal to fourteen events per hour with documentation of either of the following:
(I) Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or
(II) Hypertension, ischemic heart disease, or history of stroke.
(c) The agency considers any of the following indications medically necessary for clients age twenty and younger:
(i) OSA suspected based on clinical assessment;
(ii) Obesity, Trisomy 21, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidosis (MPS), prior to adenotonsillectomy in a child;
(iii) Residual symptoms of OSA following mild preoperative OSA;
(iv) Residual symptoms of OSA in a child with preoperative evidence of moderate to severe OSA, obesity, craniofacial anomalies that obstruct the upper airway, or neurologic disorder following adenotonsillectomy;
(v) Titration of positive airway pressure in a child with OSA;
(vi) Suspected congenital central alveolar hypoventilation syndrome or sleep related hypoventilation due to neuromuscular disorder or chest wall deformities;
(vii) Primary apnea of infancy;
(viii) Evidence of a sleep-related breathing disorder in an infant who has experienced an apparent life threatening event;
(ix) Child being considered for adenotonsillectomy to treat OSA; or
(x) Clinical suspicion of an accompanying sleep-related breathing disorder in a child with chronic asthma, cystic fibrosis, pulmonary hypertension, bronchopulmonary dysplasia, or chest wall abnormality.
(7) Noncoverage. The agency does not cover sleep studies:
(a) When documentation for a repeat study does not indicate medical necessity (e.g., no new clinical documentation indicating the need for a repeat study); or
(b) For the following indications, except when an underlying physiology exists (e.g., loud snoring, awakening with gasping or choking, excessive daytime sleepiness, observed cessation of breathing during sleep, etc.):
(i) Chronic insomnia; and
(ii) Snoring.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-11-106, § 182-531-1500, filed 5/21/18, effective 7/1/18; WSR 16-13-158, § 182-531-1500, filed 6/22/16, effective 7/23/16; WSR 15-20-057, § 182-531-1500, filed 10/1/15, effective 11/1/15. Statutory Authority: RCW 41.05.021. WSR 13-07-029, § 182-531-1500, filed 3/13/13, effective 4/13/13. WSR 11-14-075, recodified as § 182-531-1500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1500, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1500, filed 12/6/00, effective 1/6/01.]



182-531-1550
Sterilization physician-related services.

(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.
Hysterectomy results in sterilization and is not covered by the medicaid agency solely for that purpose. (See WAC 182-531-0150 and 182-531-0200 for more information about hysterectomies.)
sterilization
(2) The medicaid agency covers sterilization when all of the following apply:
(a) The client is at least eighteen years of age at the time an agency-approved consent form is signed;
(b) The client is a mentally competent individual;
(c) The client participates in a medical assistance program (see WAC 182-501-0060);
(d) The client has voluntarily given informed consent; and
(e) The date the client signed a sterilization consent is at least thirty days and not more than one hundred eighty days before the date of the sterilization procedure.
(3) Any medicaid provider who is licensed to do sterilizations within their scope of practice may provide vasectomies and tubal ligations to any medicaid client. (See subsections (10), (11), and (12) of this section for additional qualifications of providers performing hysteroscopic sterilizations.)
(4) The medicaid agency requires at least a seventy-two hour waiting period rather than the usual thirty-day waiting period for sterilization in either of the following circumstances:
(a) At the time of a premature delivery when 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.)
(5) The medicaid agency 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.
(6) The medicaid agency does not accept informed consent obtained when the client is:
(a) In labor or childbirth;
(b) In the process of seeking to obtain or obtaining an abortion; or
(c) Under the influence of alcohol or other substances, including pain medications for labor and delivery, that affects the client's state of awareness.
(7) The medicaid agency has certain consent requirements that the provider must meet before the agency reimburses sterilization of an institutionalized client or a client with mental incompetence. The agency requires both of the following:
(a) A court order, which includes both a statement that the client is to be sterilized, and the name of the client's legal guardian who will be giving consent for the sterilization; and
(b) A sterilization consent form signed by the legal guardian, sent to the agency at least thirty days before the procedure.
(8) The medicaid agency reimburses epidural anesthesia in excess of the six-hour limit for deliveries if sterilization procedures are performed in conjunction with or immediately following a delivery.
(a) For reimbursement, anesthesia time for sterilization is added to the time for the delivery when the two procedures are performed during the same operative session.
(b) If the sterilization and delivery are performed during different operative sessions, the anesthesia time is calculated separately.
(9) The medicaid agency reimburses all attending providers for the sterilization procedure only when the provider submits an agency-approved and complete consent form with the claim for reimbursement. (See subsections (10), (11), and (12) of this section for additional coverage criteria for hysteroscopic sterilizations.)
(a) The physician must complete and sign the physician statement on the consent form within thirty days of the sterilization procedure.
(b) The agency reimburses attending providers after the procedure is completed.
hysteroscopic sterilizations
(10) The medicaid agency pays for hysteroscopic sterilizations when the following additional criteria are met:
(a) A device covered by the agency is used.
(b) The procedure is predominately performed in a clinical setting, such as a physician's office, without general anesthesia and without the use of a surgical suite; and is covered according to the corresponding agency fee schedule.
(c) If determining that it is medically necessary to perform the procedure in an inpatient rather than outpatient setting, a provider must submit clinical notes with the claim, documenting the medical necessity.
(d) The client provides informed consent for the procedure.
(e) The hysteroscopic sterilization is performed by an approved provider who:
(i) Has a core provider agreement with the agency;
(ii) Is nationally board certified in obstetrics and gynecology (OB-GYN);
(iii) Is privileged at a licensed hospital to do hysteroscopies;
(iv) Has successfully completed the manufacturer's training for the device covered by the agency;
(v) Has successfully performed a minimum of twenty hysteroscopies; and
(vi) Has established screening and follow-up protocols for clients being considered for hysteroscopic sterilization.
(11) To become approved for hysteroscopic sterilizations, interested providers must send the medicaid agency-approved vendor, identified in the agency's billing instructions, the following:
(a) Documentation of successful completion of the manufacturer's training;
(b) Documentation demonstrating privilege at a licensed hospital to perform hysteroscopies;
(c) Documentation attesting to having successfully performed twenty or more hysteroscopies;
(d) Evidence of valid National Board Certification; and
(e) Office protocols for screening and follow-up.
(12) The provider will not be paid to perform the hysteroscopic procedure until the medicaid agency sends written approval to the provider.
[Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-531-1550, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-531-1550, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-24-071, § 388-531-1550, filed 11/30/10, effective 1/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1550, filed 12/6/00, effective 1/6/01.]



182-531-1600
Bariatric surgery.

(1) The agency covers medically necessary bariatric surgery for eligible clients.
(2) Bariatric surgery must be performed in a hospital with a bariatric surgery program, and the hospital must be:
(a) Located in the state of Washington or approved border cities (see WAC 182-501-0175); and
(b) Meet the requirements of WAC 182-550-2301.
(3) If bariatric surgery is requested or prescribed under the EPSDT program, the agency evaluates it as a covered service under EPSDT's standard of coverage that requires the service to be:
(a) Medically necessary;
(b) Safe and effective; and
(c) Not experimental.
(4) The agency authorizes payment for bariatric surgery and bariatric surgery-related services in three stages:
(a) Stage one - Initial assessment of client;
(b) Stage two - Evaluations for bariatric surgery and successful completion of a weight loss regimen; and
(c) Stage three - Bariatric surgery.
Stage one - Initial assessment
(5) Any agency-enrolled provider who is licensed to practice medicine in the state of Washington may examine a client requesting bariatric surgery to ascertain if the client meets the criteria listed in subsection (6) of this section.
(6) The client meets the preliminary conditions of stage one when:
(a) The client is:
(i) Twenty-one through fifty-nine years of age; or
(ii) Eighteen through twenty years old for laparoscopic adjustable gastric banding (LAGB) only;
(b) The client has a body mass index (BMI) of thirty-five or greater;
(c) The client is not pregnant. (Pregnancy within the first two years following bariatric surgery is not recommended. When applicable, a family planning consultation is highly recommended prior to bariatric surgery);
(d) The client is diagnosed with one of the following:
(i) Diabetes mellitus;
(ii) Degenerative joint disease of a major weight bearing joint(s) (the client must be a candidate for joint replacement surgery if weight loss is achieved); or
(iii) Other rare comorbid conditions (such as pseudo tumor cerebri) in which there is medical evidence that bariatric surgery is medically necessary and that the benefits of bariatric surgery outweigh the risk of surgical mortality; and
(e) The client has an absence of other medical conditions such as multiple sclerosis (MS) that would increase the client's risk of surgical mortality or morbidity from bariatric surgery.
(7) If a client meets the criteria in subsection (6) of this section, the provider must request prior authorization from the agency before referring the client to stage two of the bariatric surgery authorization process. The provider must attach a medical report to the request for prior authorization with supporting documentation that the client meets the stage one criteria in subsections (5) and (6) of this section.
(8) The agency 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 provisions of WAC 182-501-0165 and 182-501-0169.
Stage two - Evaluations for bariatric surgery and successful completion of a weight loss regimen
(9) After receiving prior authorization from the agency to begin stage two of the bariatric surgery authorization process, the client must:
(a) Undergo a comprehensive psychosocial evaluation performed by a psychiatrist, licensed psychiatric ARNP, or licensed independent social worker with a minimum of two years postmasters' experience in a mental health setting. Upon completion, the results of the evaluation must be forwarded to the agency. The comprehensive psychosocial evaluation must include:
(i) An assessment of the client's mental status or illness to:
(A) Evaluate the client for the presence of substance abuse problems or psychiatric illness which would preclude the client from participating in presurgical dietary requirements or postsurgical lifestyle changes; and
(B) If applicable, document that the client has been successfully treated for psychiatric illness and has been stabilized for at least six months and/or has been rehabilitated and is free from any drug and/or alcohol abuse and has been drug and/or alcohol free for a period of at least one year.
(ii) An assessment and certification of the client's ability to comply with the postoperative requirements such as lifelong required dietary changes and regular follow-up.
(b) Undergo an internal medicine evaluation performed by an internist to assess the client's preoperative condition and mortality risk. Upon completion, the internist must forward the results of the evaluation to the agency.
(c) Undergo a surgical evaluation by the surgeon who will perform the bariatric surgery (see subsection (13) of this section for surgeon requirements). Upon completion, the surgeon must forward the results of the surgical evaluation to the agency and to the licensed medical provider who is supervising the client's weight loss regimen (refer to WAC 182-531-1600 (9)(d)(ii)).
(d) Under the supervision of a licensed medical provider, the client must participate in a weight loss regimen prior to surgery. The client must, within one hundred and eighty days from the date of the agency's stage one authorization, lose at least five percent of his or her initial body weight. If the client does not meet this weight loss requirement within one hundred and eighty days from the date of the agency's initial authorization, the agency will cancel the authorization. The client or the client's provider must reapply for prior authorization from the agency to restart stage two. For the purpose of this section, "initial body weight" means the client's weight at the first evaluation appointment.
(i) The purpose of the weight loss regimen is to help the client achieve the required five percent loss of initial body weight prior to surgery and to demonstrate the client's ability to adhere to the radical and lifelong behavior changes and strict diet that are required after bariatric surgery.
(ii) The weight loss regimen must:
(A) Be supervised by a licensed medical provider who has a core provider agreement with the agency;
(B) Include monthly visits to the medical provider;
(C) Include counseling twice a month by a registered dietician referred to by the treating provider or surgeon; and
(D) Be at least six months in duration.
(iii) Documentation of the following requirements must be retained in the client's medical file. Copies of the documentation must be forwarded to the agency upon completion of stage two. The agency will evaluate the documentation and authorize the client for bariatric surgery if the stage two requirements were successfully completed.
(A) The provider must document the client's compliance in keeping scheduled appointments and the client's progress toward weight loss by serial weight recordings. The client must lose at least five percent of his or her initial body weight and must maintain the five percent weight loss until surgery;
(B) For diabetic clients, the provider must document the efforts in diabetic control or stabilization;
(C) The registered dietician must document the client's compliance (or noncompliance) in keeping scheduled appointments, and the client's weight loss progress;
(D) The client must keep a journal of active participation in the medically structured weight loss regimen including the activities under (d)(iii)(A), (d)(iii)(B) if appropriate, and (d)(iii)(C) of this subsection.
(10) If the client fails to complete all of the requirements of subsection (9) of this section, the agency will not authorize stage three - Bariatric surgery.
(11) If the client is unable to meet all of the stage two criteria, the client or the client's provider must reapply for prior authorization from the agency to reenter stage two.
Stage three - Bariatric surgery
(12) The agency may withdraw authorization of payment for bariatric surgery at any time up to the actual surgery if the agency determines that the client is not complying with the requirements of this section.
(13) A surgeon who performs bariatric surgery for medical assistance clients must:
(a) Have a signed core provider agreement with the agency;
(b) Have a valid medical license in the state of Washington; and
(c) Be affiliated with a bariatric surgery program that meets the requirements of WAC 182-550-2301.
(14) For hospital requirements for stage three - Bariatric surgery, see WAC 182-550-2301.
[Statutory Authority: RCW 41.05.021. WSR 13-14-016, § 182-531-1600, filed 6/21/13, effective 7/22/13. WSR 11-14-075, recodified as § 182-531-1600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-531-1600, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-12-022, § 388-531-1600, filed 5/20/05, effective 6/20/05; WSR 01-01-012, § 388-531-1600, filed 12/6/00, effective 1/6/01.]



182-531-1625
Outpatient hemophilia treatment requirements—Center of excellence.

A hemophilia treatment center of excellence (COE) uses a comprehensive care model to provide care for persons with bleeding disorders. The comprehensive care model includes specialized prevention, diagnostic, and treatment programs designed to provide family-centered education, state-of-the-art treatment, research, and support services for individuals and families living with bleeding disorders.
(1) The agency pays for hemophilia and von Willebrand related products for administration in the home only when provided through a qualified hemophilia treatment COE.
(2) To become a qualified hemophilia treatment COE, a hemophilia center must meet all of the following:
(a) Have a current core provider agreement in accordance with WAC 182-502-0005;
(b) Be a federally approved hemophilia treatment center (HTC) as defined in WAC 182-531-0050 and meet or exceed all Medical and Scientific Advisory Council (MASAC) standards of care and delivery of services;
(c) Participate in the public health service 340B provider drug discount program and be listed in the medicaid exclusion files maintained by the federal Health Resources and Services Administration (HRSA) Office of Pharmacy Affairs (OPA);
(d) Submit a written request to the agency to be a qualified hemophilia treatment center of excellence and include proof of the following:
(i) U.S. Center for Disease Control (CDC) and prevention surveillance site identification number; and
(ii) Listing in the hemophilia treatment center (HTC) directory.
(e) Receive written approval including conditions of payment and billing procedures from the agency.
(3) To continue as a qualified hemophilia treatment COE, the HTC must annually submit to the agency:
(a) Copies of grant documents and reports submitted to the maternal and child health bureau/human resources and services administration/department of health and human services or to their designated subcontractors; and
(b) Proof of continued federal funding by the National Hemophilia Program and listing with the regional hemophilia network and the CDC.
(4) Services rendered by a hemophilia treatment COE may be subject to the agency's limitations and authorization requirements.
[Statutory Authority: RCW 41.05.021. WSR 12-16-061, § 182-531-1625, filed 7/30/12, effective 11/1/12.]



182-531-1650
Substance abuse detoxification physician-related services.

(1) The department covers physician services for three-day alcohol detoxification or five-day drug detoxification services for a client eligible for medical care program services in a department-enrolled hospital-based detoxification center.
(2) The department covers treatment in programs certified under chapter 388-805 WAC or its successor.
(3) The department covers detoxification and medical stabilization services to chemically using pregnant (CUP) women for up to twenty-seven days in an inpatient hospital setting.
[WSR 11-14-075, recodified as § 182-531-1650, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1650, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. WSR 03-19-081, § 388-531-1650, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1650, filed 12/6/00, effective 1/6/01.]



182-531-1675
Washington apple healthGender dysphoria treatment program.

(1) Overview of the gender dysphoria treatment program.
(a) The medicaid agency covers the following services, consistent with the program rules described in Title 182 WAC, to treat gender dysphoria:
(i) Medical services including, but not limited to:
(A) Presurgical and postsurgical hormone therapy;
(B) Prepuberty suppression therapy;
(ii) Mental health services; and
(iii) Surgical services including, but not limited to:
(A) Anesthesia;
(B) Labs;
(C) Pathology;
(D) Radiology;
(E) Hospitalization;
(F) Physician services; and
(G) Hospitalizations and physician services required to treat postoperative complications of procedures performed under component four.
(b) The agency's gender dysphoria treatment program has four components. Prior authorization is required for services provided in component four only. Any medicaid provider can refer a client to component one. These components are not intended to be sequential and may run concurrently to meet the client's medical needs. The components are as follows:
(i) Component one - Initial assessment and diagnosis of gender dysphoria;
(ii) Component two - Mental health and medical treatment;
(iii) Component three - Presurgical requirements for prior authorization for component four; and
(iv) Component four - Gender reassignment surgery.
(c) All services under this program must be delivered by providers who meet the qualifications in subsection (2) of this section.
(d) The agency evaluates requests for clients under age twenty-one according to the early and periodic screening, diagnosis, and treatment (EPSDT) program described in chapter 182-534 WAC. Under the EPSDT program, a service may be covered if it is medically necessary, safe, effective, and not experimental.
(e) The agency covers transportation services under the provisions of chapter 182-546 WAC.
(f) Any out-of-state care, including a presurgical consultation, must be approved as an out-of-state service under WAC 182-501-0182.
(2) Qualified health care providers for gender dysphoria treatment.
(a) Providers must meet the qualifications outlined in chapter 182-502 WAC.
(b) Each provider must be recognized as an agency-designated center of excellence (COE). COE is defined in WAC 182-531-0050. To be a COE, all providers must complete an agency form attesting that they:
(i) Possess knowledge about current community, advocacy, and public policy issues relevant to transgender people and their families (knowledge about sexuality, sexual health concerns, and the assessment and treatment of sexual disorders is preferred);
(ii) Endorse the Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7 as developed by the World Professional Association for Transgender Health (WPATH); and
(iii) Agree to provide services consistent with this section. The agency's forms are available online at http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx.
(c) Diagnosis in component one must be made or confirmed by a COE provider who is a board certified physician, a psychologist, a board certified psychiatrist, or a licensed advanced registered nurse practitioner (ARNP).
(d) Mental health professionals who provide component two mental health treatment described in subsection (4)(d) of this section, or who perform the psychosocial evaluation described in subsection (5)(a)(iii) of this section must:
(i) Meet the requirements described in WAC 182-531-1400;
(ii) Sign the agency's form (HCA 18-493) attesting that they:
(A) Are competent in using the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the International Classification of Diseases for diagnostic purposes;
(B) Are able to recognize and diagnose coexisting mental health conditions and to distinguish these from gender dysphoria;
(C) Have completed supervised training in psychotherapy or counseling;
(D) Are knowledgeable of gender-nonconforming identities and expressions, and the assessment and treatment of gender dysphoria; and
(E) Have completed continuing education in the assessment and treatment of gender dysphoria. This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria; and
(iii) Be a board certified psychiatrist, a psychologist, or a licensed:
(A) Psychiatric ARNP;
(B) Psychiatric mental health nurse practitioner;
(C) Mental health counselor;
(D) Independent clinical social worker;
(E) Advanced social worker; or
(F) Marriage and family therapist.
(e) Any surgeon who performs gender reassignment surgery must:
(i) Be a board certified or board qualified:
(A) Urologist;
(B) Gynecologist;
(C) Plastic surgeon;
(D) Cosmetic surgeon; or
(E) General surgeon;
(ii) Have a valid medical license in the state where the surgery is performed; and
(iii) Sign the agency's form (HCA 18-492) attesting to specialized abilities in genital reconstructive techniques and produce documentation showing that they have received supervised training with a more experienced surgeon.
(f) Any medical provider managing hormone therapy, androgen suppression, or puberty suppression for clients diagnosed with gender dysphoria must:
(i) Be either of the following:
(A) A licensed, board certified, or board qualified:
(I) Endocrinologist;
(II) Family practitioner;
(III) Internist;
(IV) Obstetrician/gynecologist;
(V) Pediatrician;
(VI) Naturopath; or
(B) A licensed ARNP or a licensed physician's assistant; and
(ii) Sign the agency's form (HCA 18-494) attesting to specialized abilities managing hormone therapy in treating gender dysphoria. The specialized abilities may be proved by producing documentation showing supervised training with a more experienced physician, and attesting attendance at relevant professional meetings, workshops, or seminars.
(3) Component one – Initial assessment and diagnosis of gender dysphoria. The purpose of component one is to assess and diagnose the client, and refer the client to other qualified providers as needed for additional medically necessary services. A health professional who meets the qualifications in subsection (2)(c) of this section must assess the client and:
(a) Confirm the diagnosis of gender dysphoria as defined by the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5);
(b) Determine the gender dysphoria is not the result of another mental or physical health condition, and refer the client to other specialists if other health conditions are indicated;
(c) Develop an individualized treatment plan for the client;
(d) Refer the client to qualified providers for the component two services described in subsection (4) of this section; and
(e) Assist and support the client in navigating component two and component three requirements, and provide services consistent with WPATH guidelines and WAC 182-531-1675.
(4) Component two – Mental health and medical treatment.
(a) Clients enrolled with an agency managed care organization (MCO) plan are subject to the respective plan's policies and procedures for coverage of these services.
(b) Mental health and medical treatment are covered after a health professional who meets the qualifications in subsection (2)(c) of this section has diagnosed, or confirmed the diagnosis of, gender dysphoria as defined by the DSM-5 criteria.
(c) Medical treatment in component two covers androgen suppression, puberty suppression, continuous hormone therapy, and laboratory testing to monitor the safety of hormone therapy. Some of these prescriptions may be subject to prior authorization as required by pharmacy policy in chapter 182-530 WAC. Medical treatment must be prescribed by a COE provider who meets the requirements in subsection (2)(a), (b), and (f) of this section.
(d) The agency covers mental health treatment for the client and the client's spouse, parent, guardian, child, or person with whom the client has a child in common if the treatment is:
(i) Medically necessary;
(ii) Provided according to the provisions of WAC 182-531-1400; and
(iii) Provided by a health professional who meets the requirements in subsection (2)(a), (b), and (d) of this section.
(5) Component three – Presurgical requirements.
(a) To proceed to component four gender reassignment surgery, the client must:
(i) Be age eighteen or older, unless allowed under EPSDT as described in subsection (1)(d) of this section;
(ii) Be competent to give consent for treatment and have this competency documented in clinical records; and
(iii) Undergo a comprehensive psychosocial evaluation that must do all of the following:
(A) Be conducted by two mental health professionals for genital surgery and one mental health professional for chest surgery. These mental health professionals must meet the qualifications described in subsection (2)(d) of this section.
(B) Confirm the diagnosis of gender dysphoria, document that professionals performing the evaluation believe the client is a good candidate for gender reassignment surgery, and document that surgery is the next reasonable step in the client's care.
(C) Evaluate the client for the presence of coexisting behavioral health conditions (substance abuse problems, or mental health illnesses), which could prevent the client from participating in gender dysphoria treatment including, but not limited to, gender reassignment surgery and postsurgical care.
(D) Document that any coexisting behavioral health condition is adequately managed.
(b) The surgeon who will perform the gender reassignment surgery and who meets the qualifications outlined in subsection (2)(a), (b), and (e) of this section, must complete a presurgical consultation. When the presurgical consultation is completed, the surgeon must forward the report of the consultation to the other treatment team members.
(c) The client must have received continuous hormone therapy as required by the treatment plan to meet treatment objectives. For exceptions, see subsection (6)(b) of this section.
(d) The client must have lived in a gender role congruent with the client's gender identity immediately preceding surgery as required by the treatment plan to meet treatment objectives. For exceptions, see subsection (6)(b) of this section.
(e) The client's medical record must document that the client met the requirements in (a) through (d) of this subsection.
(f) A member of the treatment team must write a referral letter and submit it to the agency along with the prior authorization request for surgery. The contents of the referral letter or its attachments must include:
(i) Results of the client's psychosocial evaluation, as described in (a)(iii) of this subsection;
(ii) Documentation that any coexisting behavioral health condition is adequately managed;
(iii) A description of the relationship between the mental health professionals and the client, including the duration of the professional relationship, and the type of evaluation and therapy or counseling to date;
(iv) A brief description of the clinical justification supporting the client's request for surgery;
(v) An assessment and attestation that the provider believes the client is able to comply with the postoperative requirements, has the capacity to maintain lifelong changes, and will comply with regular follow up;
(vi) A statement about the client's adherence to the medical and mental health treatment plan;
(vii) A description of the outcome of the client's hormone therapy;
(viii) A copy of the client's signed informed consent according to the requirements under WAC 182-531-1550, or written acknowledgment of the permanent impact on male and female reproductive capacity if WAC 182-531-1550 is not applicable;
(ix) A statement that all the members of the treatment team will be available to coordinate or provide postoperative care as needed;
(x) A description of the surgical plan. See subsection (6)(d) and (e) of this section, covered and noncovered procedures. The description must:
(A) List all planned surgical procedures, including any listed in subsection (6)(e) of this section, with clinical justification; and
(B) Provide a timeline of surgical stages if clinically indicated; and
(xi) Signatures from the following treatment team members:
(A) The two mental health professionals for genital surgery and one mental health professional for chest surgery who completed the responsibilities described in subsection (4)(d) of this section and (a)(iii) of this subsection;
(B) The medical provider who has managed the care;
(C) Any surgeon performing the procedures; and
(D) The client.
(6) Component four – Gender reassignment surgery.
(a) The agency requires prior authorization for component four. Subsection (5) of this section lists the documentation that is required to be submitted with the authorization requests. Surgeries are not required to be completed at the same time. Surgeries may be performed in progressive stages.
(b) If the client fails to complete all of the requirements in subsection (5) of this section, the agency will not authorize gender reassignment surgery unless the clinical decision-making process is provided in the referral letter and attachments described in subsection (5)(f) of this section.
(c) A client preparing for gender reassignment surgery must be cared for by a treatment team consisting of:
(i) One of the mental health professionals described in subsection (2)(d) of this section, if mental health services are part of the treatment plan;
(ii) The medical provider who managed the medical care in component two and component three; and
(iii) Any surgeon performing the procedures.
(d) The agency covers the following procedures in component four with prior authorization:
(i) Abdominoplasty;
(ii) Belpharoplasty;
(iii) Breast reconstruction (male to female);
(iv) Bilateral mastectomy with or without chest reconstruction;
(v) Cliteroplasty;
(vi) Colovaginoplasty;
(vii) Colpectomy;
(viii) Genital surgery;
(ix) Genital electrolysis as required as part of the genital surgery;
(x) Hysterectomy;
(xi) Labiaplasty;
(xii) Laryngoplasty;
(xiii) Metoidioplasty;
(xiv) Orchiectomy;
(xv) Penectomy;
(xvi) Phalloplasty;
(xvii) Placement of testicular prosthesis;
(xviii) Rhinoplasty;
(xix) Salpingo-oophorectomy;
(xx) Scrotoplasty;
(xxi) Urethroplasty;
(xxii) Vaginectomy; and
(xxiii) Vaginoplasty.
(e) For the purposes of this section, the agency will review on a case-by-case basis and may pay for the following noncovered services under exception to rule:
(i) Cosmetic procedures and services:
(A) Brow lift;
(B) Calf implants;
(C) Cheek/malar implants;
(D) Chin/nose implants;
(E) Collagen injections;
(F) Drugs for hair loss or growth;
(G) Facial or trunk electrolysis, except for the limited electrolysis described in (d)(ix) of this subsection;
(H) Facial feminization;
(I) Face lift;
(J) Forehead lift;
(K) Hair transplantation;
(L) Jaw shortening;
(M) Lip reduction;
(N) Liposuction;
(O) Mastopexy;
(P) Neck tightening;
(Q) Pectoral implants;
(R) Reduction thyroid chondroplasty;
(S) Removal of redundant skin;
(T) Suction-assisted lipoplasty of the waist; and
(U) Trachea shave;
(ii) Voice modification surgery; and
(iii) Voice therapy.
(f) The agency evaluates a request for any noncovered service listed in (e) of this subsection as an exception to rule under the provisions of WAC 182-501-0160. The justification included in the surgical plan for any of the procedures listed in (e) of this subsection may be recognized by the agency as meeting the documentation requirements of WAC 182-501-0160.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 15-16-084, § 182-531-1675, filed 7/31/15, effective 8/31/15.]



182-531-1700
Surgical physician-related services.

(1) The agency'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) The agency'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) The agency'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, the agency does not include these services in the global surgical reimbursement. The physician may bill these services separately.
(5) The agency'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 the agency's allowed fee for the highest value procedure. Then,
(b) For additional surgical procedures, payment equals fifty percent of the agency's allowed fee for each procedure.
(6) The agency 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) The agency'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, the agency pays the full amount of the procedure with the highest maximum allowable fee.
(d) The agency 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) The agency does not pay when payment for other codes within an endoscopy group is less than the base code.
(8) The agency restricts reimbursement for surgery assists to selected procedures as follows:
(a) The agency applies multiple surgery reimbursement rules for surgery assists. 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) The agency bases payment splits between preoperative, intraoperative, and postoperative services on medicare determinations for given surgical procedures or range of procedures. The agency 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 182-531-0450.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 17-04-039, § 182-531-1700, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-1700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1700, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1700, filed 12/6/00, effective 1/6/01.]



182-531-1710
Alcohol and substance misuse counseling.

(1) The medicaid agency covers alcohol and substance misuse counseling through screening, brief intervention, and referral to treatment (SBIRT) services when delivered by, or under the supervision of, a qualified licensed physician or other qualified licensed health care professional within the scope of their practice.
(2) SBIRT is a comprehensive, evidence-based public health practice designed to identify, reduce and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. SBIRT can be used to identify people who are at risk for or have some level of substance use disorder which can lead to illness, injury, or other long-term morbidity or mortality. SBIRT services are provided in a wide variety of medical and community health care settings such as primary care centers, hospital emergency rooms, trauma centers, and dental offices.
(3) The following health care professionals are eligible to become qualified SBIRT providers to deliver SBIRT services or supervise qualified staff to deliver SBIRT services:
(a) Advanced registered nurse practitioners, in accordance with chapters 18.79 RCW and 246-840 WAC;
(b) Chemical dependency professionals, in accordance with chapters 18.205 RCW and 246-811 WAC;
(c) Licensed practical nurses, in accordance with chapters 18.79 RCW and 246-840 WAC;
(d) Mental health counselors, in accordance with chapters 18.225 RCW and 246-809 WAC;
(e) Marriage and family therapists, in accordance with chapters 18.225 RCW and 246-809 WAC;
(f) Independent and advanced social workers, in accordance with chapters 18.225 RCW and 246-809 WAC;
(g) Physicians, in accordance with chapters 18.71 RCW and 246-919 WAC;
(h) Physician assistants, in accordance with chapters 18.71A RCW and 246-918 WAC;
(i) Psychologists, in accordance with chapters 18.83 RCW and 246-924 WAC;
(j) Registered nurses, in accordance with chapters 18.79 RCW and 246-840 WAC;
(k) Dentists, in accordance with chapters 18.260 and 246-817; and
(l) Dental hygienists, in accordance with chapters 18.29 and 246-815 WAC.
(4) To become a qualified SBIRT provider, eligible licensed health care professionals must:
(a) Complete agency-approved SBIRT training and mail or fax the SBIRT training certificate or other proof of this training completion to the agency; or
(b) Have an addiction specialist certification and mail or fax proof of this certification to the agency.
(5) The agency pays for SBIRT as follows:
(a) Screenings, which are included in the reimbursement for the evaluation and management code billed;
(b) Brief interventions, limited to four sessions per client, per provider, per calendar year; and
(c) When billed by one of the following qualified SBIRT health care professionals:
(i) Advanced registered nurse practitioners;
(ii) Mental health counselors;
(iii) Marriage and family therapists;
(iv) Independent and advanced social workers;
(v) Physicians;
(vi) Psychologists;
(vii) Dentists; and
(viii) Dental hygienists.
(6) The agency evaluates a request for additional sessions in excess of the limitations or restrictions according to WAC 182-501-0169.
(7) To be paid for providing alcohol and substance misuse counseling through SBIRT, providers must bill the agency using the agency's published billing instructions.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-12-045, § 182-531-1710, filed 5/30/18, effective 7/1/18; WSR 15-03-041, § 182-531-1710, filed 1/12/15, effective 2/12/15.]



182-531-1720
Tobacco cessation counseling.

(1) The medicaid agency covers tobacco cessation counseling when delivered by qualified providers through the agency contracted quitline or during face-to-face office visits for tobacco cessation for pregnant clients.
(2) The agency pays for face-to-face office visits for tobacco cessation counseling for pregnant clients with the following limits:
(a) When provided by physicians, advanced registered nurse practitioners (ARNPs), physician assistants-certified (PA-Cs), naturopathic physicians, and dentists;
(b) Two cessation counseling attempts (or up to eight sessions) are allowed every twelve months. An attempt is defined as up to four cessation counseling sessions.
(3) To be paid for tobacco cessation counseling through SBIRT, providers must bill the agency using the agency's published billing instructions.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 15-03-041, § 182-531-1720, filed 1/12/15, effective 2/12/15.]



182-531-1730
Telemedicine.

(1) Telemedicine is when a health care practitioner uses HIPAA-compliant, interactive, real-time audio and video telecommunications (including web-based applications) or store and forward technology to deliver covered services that are within his or her scope of practice to a client at a site other than the site where the provider is located. If the service is provided through store and forward technology, there must be an associated office visit between the client and the referring health care provider.
(2) The medicaid agency does not cover the following services as telemedicine:
(a) Email, audio only telephone, and facsimile transmissions;
(b) Installation or maintenance of any telecommunication devices or systems; and
(c) Purchase, rental, or repair of telemedicine equipment.
(3) Originating site. An originating site is the physical location of the client at the time the health care service is provided. Approved originating sites are:
(a) Clinics;
(b) Community mental health/chemical dependency settings;
(c) Dental offices;
(d) Federally qualified health centers;
(e) Home or any location determined appropriate by the individual receiving the service;
(f) Hospitals - Inpatient and outpatient;
(g) Neurodevelopmental centers;
(h) Physician or other health professional's office;
(i) Renal dialysis centers, except an independent renal dialysis center;
(j) Rural health clinics;
(k) Schools; and
(l) Skilled nursing facilities.
(4) Distant site. A distant site is the physical location of the health care professional providing the health care service.
(5) The agency pays an additional facility fee per completed transmission to either the originating site or the distant site, as specified in the agency's program-specific billing instructions.
(6) If a health care professional performs a separately identifiable service for the client on the same day as the telemedicine service, documentation for both services must be clearly and separately identified in the client's medical record.
(7) Billing procedures for telemedicine can be found in the agency's program-specific billing instructions.
[Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.700. WSR 19-11-122, § 182-531-1730, filed 5/22/19, effective 6/22/19. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 15-20-063, § 182-531-1730, filed 10/1/15, effective 11/1/15.]



182-531-1750
Transplant coverage for physician-related services.

The medicaid agency covers transplants when performed in an agency-approved center of excellence. See WAC 182-550-1900 for information regarding transplant coverage.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 17-04-039, § 182-531-1750, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-1750, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1750, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1750, filed 12/6/00, effective 1/6/01.]



182-531-1800
Transplant coverageMedical criteria to receive transplants.

See WAC 182-550-2000 for information about medical criteria to receive transplants.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 17-04-039, § 182-531-1800, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-1800, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1800, filed 12/6/00, effective 1/6/01.]



182-531-1850
Payment methodology for physician-related servicesGeneral and billing modifiers.

GENERAL PAYMENT METHODOLOGY
(l) The medicaid agency bases the payment methodology for most physician-related services on medicare's RBRVS. The agency obtains information used to update the agency's RBRVS from the MPFSPS.
(2) The agency updates and revises the following RBRVS areas each January prior to the agency's annual update.
(3) The agency 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. Then,
(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) The agency 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, the agency establishes maximum allowable fees, also known as "flat" fees.
(i) The agency does not use the conversion factor for these codes.
(ii) The agency 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 the medicare Part B drug file price or POS AAC when there is no Part B rate. (See WAC 182-530-1050 for explanation of POS AAC.) When the provider receives immunization materials from the department of health, the agency pays only a flat fee 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, the agency 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) The agency 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) The agency 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 the agency's annual update.
(7) If the legislatively authorized vendor rate increase, or other increase, becomes effective at the same time as the annual update, the agency applies the increase after calculating budget-neutral fees. The agency pays providers a higher reimbursement rate for primary health care E&M services that are provided to children age twenty and under.
(8) The agency does not allow separate reimbursement for bundled services. However, the agency 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 the agency to reimburse the provider. This information is included in the sections dealing with those particular services and procedures, as well as the fee schedule.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-21-040, § 182-531-1850, filed 10/12/17, effective 11/12/17; WSR 17-04-039, § 182-531-1850, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-1850, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1850, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1850, filed 12/6/00, effective 1/6/01.]



182-531-1900
PaymentGeneral requirements for physician-related services.

(1) The medicaid agency pays 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) To receive payment, physicians must bill the agency according to the conditions of payment under WAC 182-502-0100.
(3) The agency does not separately reimburse certain administrative costs or services. The agency considers these costs to be included in the payment. 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, and copying expenses;
(f) Service charges;
(g) Take home drugs; and
(h) Telephoning (e.g., for prescription refills).
(4) The agency does not routinely pay for procedure codes which have a "#" or "NC" indicator in the fee schedule. The agency reviews these codes for conformance to medicaid program policy only as an exception to policy or as a limitation extension. See WAC 182-501-0160 and 182-501-0165.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-066, § 182-531-1900, filed 8/14/15, effective 9/14/15. WSR 11-14-075, recodified as § 182-531-1900, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1900, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1900, filed 12/6/00, effective 1/6/01.]



182-531-2000
Increased payments for physician-related services for qualified trauma cases.

(1) The health care authority's physician trauma care fund (TCF) is an amount that is legislatively appropriated to the medicaid agency each biennium for the purpose of increasing the agency's payment to physicians and other clinicians (those who are performing services within their licensed and credentialed scope of practice) providing qualified trauma care services to medical assistance clients covered under the agency's medical assistance programs.
(2) Trauma care services provided to clients in:
(a) Medicaid, disability lifeline (DL), incapacity-based medical care services (MCS), children's health insurance program (CHIP), and apple health for kids, qualify for enhanced rate payments from the TCF. Trauma care services provided to a DL or MCS client qualify for enhanced rates only during the client's certification period. See WAC 182-504-0010;
(b) The alien emergency medical (AEM), refugee assistance, and alien medical programs do not qualify for enhanced rate payments from the TCF; and
(c) The agency's managed care programs qualify for enhanced rate payments from the TCF, effective with dates of service on and after July 1, 2012.
(3) To receive payments from the TCF, a physician or other clinician must:
(a) Be on the designated trauma services response team of any department of health (DOH)-designated or DOH-recognized trauma service center;
(b) Meet the provider requirements in this section and other applicable rules;
(c) Meet the billing requirements in this section and other applicable rules; and
(d) Submit all information the agency requires to monitor the trauma program.
(4) Except as described in subsection (5) of this section and subject to the limitations listed, the agency makes payments from the TCF to physicians and other clinicians:
(a) For only those trauma services that are designated by the agency as "qualified." Qualified trauma care services include:
(i) Follow-up surgical services provided within six months of the date of the injury. These surgical procedures must have been planned during the initial acute episode of injury; and
(ii) Physiatrist services provided during an inpatient stay immediately following, and within six months of, the qualifying traumatic injury.
(b) For hospital-based professional services-only, and for follow-up surgeries performed in a medicare-certified ambulatory surgery center (ASC). The follow-up surgery must have been performed within six months of the initial traumatic injury.
(c) Only for trauma cases that meet the injury severity score (ISS) (a summary rating system for traumatic anatomic injuries) criteria specified by the agency. The current qualifying ISS are:
(i) Thirteen or greater for an adult trauma patient (a client age fifteen or older); and
(ii) Nine or greater for a pediatric trauma patient (a client younger than age fifteen).
(d) On a per-client basis in any DOH-designated or DOH-recognized trauma service center.
(e) At a rate of two and one-half times the agency's current fee-for-service rate for qualified trauma services, or other payment enhancement percentage the agency deems appropriate.
(i) The agency monitors the payments from the TCF during each state fiscal year (SFY) and makes necessary adjustments to the rate to ensure that total payments from the TCF for the SFY will not exceed the legislative appropriation for that SFY.
(ii) Laboratory and pathology charges are not eligible for payments from the TCF. (See subsection (6)(b) of this section.)
(5) When a trauma case is transferred from one hospital to another, the agency makes payments from the TCF to physicians and clinicians, according to the ISS score as follows:
(a) If the transferred case meets or exceeds the appropriate ISS threshold described in subsection (4)(c) of this section, providers who furnish qualified trauma services, whether in the transferring or receiving facility, are eligible for payments from the TCF.
(b) If the transferred case is below the ISS threshold described in subsection (4)(c) of this section, only providers who furnish qualified trauma services in the receiving hospital are eligible for payments from the TCF.
(6) The agency makes a TCF payment to a physician or clinician:
(a) Only when the provider submits an eligible trauma claim with the appropriate trauma indicator within the time frames specified by the agency; and
(b) On a per-claim basis. Each qualifying trauma service and/or procedure on the provider's claim is paid at the agency's current fee-for-service rate, multiplied by the appropriate payment enhancement percentage described in subsection (4)(e) of this section. Laboratory and pathology services and/or procedures are not eligible for payments from the TCF and are paid at the agency's current fee-for-service rate.
(7) For purposes of the payments from the TCF to physicians and other clinicians, all of the following apply:
(a) The agency considers a request for a claim adjustment submitted by a provider only if the agency receives the adjustment request within three hundred sixty-five days from the date of the initial trauma service. At its discretion, and with sufficient public notice, the agency may adjust the deadline for submission and/or adjustment of trauma claims in response to budgetary or other program needs;
(b) Except as provided in subsection (7)(a) of this section, the deadline for making adjustments to a trauma claim is the same as the deadline for submitting the initial claim to the agency as specified in WAC 182-502-0150(3). See WAC 182-502-0150 (11) and (12) for other time limits applicable to trauma claims;
(c) All claims and claim adjustments are subject to federal and state audit and review requirements; and
(d) The total payments from the TCF disbursed to providers by the agency in an SFY cannot exceed the amount appropriated by the legislature for that SFY. The agency has the authority to take whatever actions are needed to ensure the agency stays within its TCF appropriation (see subsection (4)(e)(i) of this section).
[Statutory Authority: RCW 41.05.021. WSR 12-14-041, § 182-531-2000, filed 6/27/12, effective 7/28/12. WSR 11-14-075, recodified as § 182-531-2000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 70.168.040, 74.08.090, and 74.09.500. WSR 10-12-013, § 388-531-2000, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.500, and chapter 43.20A RCW. WSR 08-18-029, § 388-531-2000, filed 8/27/08, effective 9/27/08. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 05-20-050, § 388-531-2000, filed 9/30/05, effective 10/31/05; WSR 04-19-113, § 388-531-2000, filed 9/21/04, effective 10/22/04.]



182-531-2010
Enhanced reimbursement—Independent advanced registered nurse practitioners (ARNPs).

(1) Effective for dates of service July 1, 2013, through December 31, 2014, the agency is authorized by the legislature to increase reimbursement rates to medicare levels for independent ARNPs who provide qualified primary care services to eligible medicaid clients.
(2) For the purpose of this section, the following definitions apply:
(a) Independent ARNP – Means a health care practitioner who is not supervised by an eligible primary care physician and not already receiving increased rates for evaluation and management services and vaccine administration services as provided under the Affordable Care Act, section 1202.
(b) Qualified primary care services – Means evaluation and management services and vaccine administration services provided to eligible medicaid clients.
(3) The agency calculates the enhanced rate for independent ARNPs using medicare's payment methodology.
(a) ARNP services are paid at eighty percent of the lesser of the actual charge or eighty-five percent of what a physician is paid under the medicare physician fee schedule.
(b) For the purpose of this enhanced rate calculation, the amount payable to a physician is determined by the Centers for Medicare and Medicaid Services (CMS) as authorized by C.F.R. 447.405 for qualified services in calendar years 2013 and 2014.
(4) If the enhanced rate is less than the agency's published fee schedule rate, the agency's payment will equal the published rate.
(5) This rate increase does not apply to either of the following:
(a) Federally qualified health center services and rural health clinic services reimbursed as part of the encounter rate.
(b) Services provided under state-only funded programs.
(c) Services paid at an enhanced or supplemental rate through a separate provision or regulation.
[Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213(26). WSR 14-06-049, § 182-531-2010, filed 2/26/14, effective 3/29/14.]



182-531-2020
Enhanced reimbursementLong-acting reversible contraception (LARC).

(1) Effective for dates of service on or after September 1, 2015, the medicaid agency pays enhanced rates for physician procedure codes directly related to insertion or implant of long-acting reversible contraceptives (LARC).
(2) The agency pays the enhanced rate as a set amount above the standard resource based relative value scale (RBRVS) rate calculation described in WAC 182-531-1850.
(3) The agency will pay the enhanced rate to all providers eligible to bill for these services.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-01-039, § 182-531-2020, filed 12/9/15, effective 1/9/16.]



182-531-2030
Enhanced rates for pediatric care services and administration of vaccines.

(1) Subject to available funds, the agency pays an enhanced rate for covered pediatric care services and the administration of vaccines provided to clients age eighteen and younger.
(2) For the purposes of this section, pediatric care services are defined as covered evaluation and management services.
(3) The agency uses the resource-based relative value scale (RBRVS) payment methodology described in WAC 182-531-1850 to calculate the enhanced rate.
(4) If the enhanced rate is less than the agency's published fee schedule rate, the agency pays the published rate.
(5) This enhanced rate applies only to pediatric care services and administration of vaccines for clients age eighteen and younger that are not already paid at an enhanced rate.
[Statutory Authority: RCW 41.05.021, 41.05.160, and 2018 c 299 § 213 (1)(ddd). WSR 18-17-047, § 182-531-2030, filed 8/8/18, effective 10/1/18.]



182-531-2040
Enhanced reimbursementMedication assisted treatment for opioid use disorder.

(1) The medicaid agency pays an enhanced reimbursement using the medicare rate when medication assisted treatment (MAT) is part of the visit for selected evaluation and management (E/M) codes and the provider meets the criteria in this section.
(2) The purpose of this enhanced reimbursement is to encourage providers to obtain and use a Drug Addiction Treatment Act of 2000 waiver (DATA 2000 waiver) to increase client access to evidence-based treatment using medications for opioid use disorder.
(3) To receive the enhanced reimbursement for MAT, a provider must:
(a) Bill using the agency's expedited prior authorization process;
(b) Currently use a DATA 2000 waiver to prescribe MAT to clients with opioid use disorder;
(c) Bill for treating a client with a qualifying diagnosis for opioid use disorder; and
(d) Provide opioid-related counseling during the visit.
(4) The agency payment for MAT under this section is limited to one enhanced reimbursement, per client, per day.
(5) The agency does not pay an enhanced reimbursement for services a client receives for opioid use disorder through an opioid treatment program facility licensed by the department of health.
[Statutory Authority: RCW 41.05.021, 41.05.160, and 2018 c 299. WSR 19-09-052, § 182-531-2040, filed 4/12/19, effective 5/13/19.]