Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-531 - Physician-related services
Section 182-531-0950 - Office and other outpatient physician-related services
Universal Citation: WA Admin Code 182-531-0950
Current through Register Vol. 24-18, September 15, 2024
(1) 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/health care professional 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 actual acquisition cost 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 fee schedule.
(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 intraarterial 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
actual 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 $1,100; and
(ii) Unclassified drugs where the billed
charge to the agency is over $100. 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 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 acquisition cost, after
discounts and promotions, paid by typical providers nationally or in Washington
state.
(13) The agency may request
an invoice as necessary.
11-14-075, recodified as §182-531-0950, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. 10-19-057, § 388-531-0950, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0950, filed 12/6/00, effective 1/6/01.
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