Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-550 - Hospital services
Section 182-550-1500 - Covered and noncovered revenue code categories and subcategories for outpatient hospital services
Universal Citation: WA Admin Code 182-550-1500
Current through Register Vol. 24-18, September 15, 2024
(1) The medicaid agency pays for an outpatient hospital covered service in the following revenue code categories and subcategories when the hospital provider accurately bills:
(a) "Pharmacy," only
subcategories "general classification," "generic drugs," "nongeneric drugs,"
"drugs incident to other diagnostic services," "drugs incident to radiology,"
"nonprescription," and "IV solutions";
(b) "IV therapy," only subcategories "general
classification," "infusion pump," "IV therapy/pharmacy services," "IV
therapy/drug/supply delivery," and "IV therapy/supplies";
(c) "Medical/surgical supplies and devices,"
only subcategories "general classification," "nonsterile supply," "sterile
supply," "pacemaker," "intraocular lens," and "other implant," and "other
supplies/devices";
(d) "Oncology,"
only subcategory "general classification";
(e) "Durable medical equipment (other than
renal)," only subcategory "general classification";
(f) "Laboratory," only subcategories "general
classification," "chemistry," "immunology," "renal patient (home)," "nonroutine
dialysis," "hematology," "bacteriology and microbiology," and
"urology";
(g) "Laboratory
pathology," only subcategories "general classification," "cytology,"
"histology," and "biopsy";
(h)
"Radiology - Diagnostic," only subcategories "general classification,"
"angiocardiography," "arthrography," "arteriography," and "chest
X-ray";
(i) "Radiology -
Therapeutic and/or chemotherapy administration," only subcategories "general
classification," "chemotherapy - injected," "chemotherapy - oral," "radiation
therapy," and "chemotherapy -IV";
(j) "Nuclear medicine," only subcategories
"general classification," "diagnostic," and "therapeutic," "diagnostic
radiopharmaceuticals," and "therapeutic radiopharmaceuticals";
(k) "CT scan," only subcategories "general
classification," "head scan," and "body scan";
(l) "Operating room services," only
subcategories "general classification" and "minor surgery";
(m) "Anesthesia," only subcategories "general
classification," "anesthesia incident to radiology," and "anesthesia incident
to other diagnostic services";
(n)
"Administration, processing and storage for blood and blood components," only
subcategories "general classification" and "administration";
(o) "Other imaging," only subcategories
"general classification," "diagnostic mammography," "ultrasound," "screening
mammography," and "positron emission tomography";
(p) "Respiratory services," only
subcategories "general classification," "inhalation services," and "hyperbaric
oxygen therapy";
(q) "Physical
therapy," only subcategories "general classification," "visit charge," "hourly
charge," "group rate," and "evaluation or reevaluation";
(r) "Occupational therapy," only
subcategories "general classification," "visit charge," "hourly charge," "group
rate," and "evaluation or reevaluation";
(s) "Speech therapy - Language pathology,"
only subcategories "general classification," "visit charge," "hourly charge,"
"group rate," and "evaluation or reevaluation";
(t) "Emergency room," only subcategories
"general classification" and "urgent care";
(u) "Pulmonary function," only subcategory
"general classification";
(v)
"Audiology," only subcategories "general classification," "diagnostic," and
"treatment";
(w) "Cardiology," only
subcategories "general classification," "cardiac cath lab," "stress test," and
"echocardiology";
(x) "Ambulatory
surgical care," only subcategory "general classification";
(y) "Magnetic resonance technology (MRT),"
only subcategories "general classification," "MRI - Brain (including
brainstem)," "MRI - Spinal cord (including spine)," "MRI-other," "MRA - Head
and neck," "MRA - Lower extremities" and "MRA-other";
(z) "Medical/surgical supplies - Extension,"
only subcategories "supplies incident to radiology," "supplies incident to
other diagnostic services," and "surgical dressings";
(aa) "Pharmacy - Extension," only
subcategories "single source drug," "multiple source drug," "restrictive
prescription," "erythropoietin (EPO) less than ten thousand units,"
"erythropoietin (EPO) ten thousand or more units," "drugs requiring detailed
coding," and "self-administrable drugs";
(bb) "Cast room," only subcategory "general
classification";
(cc) "Recovery
room," only subcategory "general classification";
(dd) "Labor room/delivery," only
subcategories "general classification," "labor," "delivery," and "birthing
center";
(ee) "EKG/ECG
(Electrocardiogram)," only subcategories "general classification," "holter
monitor," and "telemetry";
(ff)
"EEG (Electroencephalogram)," only subcategory "general
classification";
(gg)
"Gastro-intestinal services," only subcategory "general
classification";
(hh) "Specialty
room - Treatment/observation room," only subcategories "treatment room," and
"observation room";
(ii)
"Telemedicine," only subcategory "other telemedicine";
(jj) "Extra-corporeal shock wave therapy
(formerly lithotripsy)," subcategory "general classification";
(kk) "Acquisition of body components," only
subcategories "general classification," "living donor," and "cadaver
donor";
(ll) "Hemodialysis -
Outpatient or home," only subcategory "general classification";
(mm) "Peritoneal dialysis - Outpatient or
home," only subcategory "general classification";
(nn) "Continuous ambulatory peritoneal
dialysis (CAPD) - Outpatient or home," only subcategory "general
classification";
(oo) "Continuous
cycling peritoneal dialysis (CCPD) - Outpatient or home," only subcategory
"general classification";
(pp)
"Miscellaneous dialysis," only subcategories "general classification," and
"ultra filtration";
(qq)
"Behavioral health treatments/services," only subcategory "electroshock
treatment";
(rr) "Behavioral
health treatment/services," subcategories "intensive outpatient services -
psychiatric";
(ss) "Behavioral
health treatment/services," subcategories "partial hospitalization - less
intensive," "partial hospitalization - intensive"; and
(tt) "Other diagnostic services," only
subcategories "general classification," "peripheral vascular lab,"
"electromyelogram," "pap smear," and "pregnancy test."
(2) The agency pays for an outpatient hospital covered service in the following revenue code subcategories only when the outpatient hospital provider is approved by the agency to provide the specific service:
(a) "Clinic," subcategories
"general classification," "dental clinic," and "other clinic"; and
(b) "Other therapeutic services,"
subcategories, "general classification," "education/training," "cardiac
rehabilitation," and "other therapeutic service."
(3) The agency does not pay for outpatient hospital services in the following revenue code categories and subcategories:
(a) "All-inclusive rate";
(b) "Room & board - Private (one
bed)";
(c) "Room & board -
Semi-private (two beds)";
(d) "Room
& board - Semi-private (three and four beds)";
(e) "Room & board - Deluxe
private";
(f) "Room & board -
Ward";
(g) "Room & board -
Other";
(h) "Nursery";
(i) "Leave of absence";
(j) "Subacute care";
(k) "Intensive care unit";
(l) "Coronary care unit";
(m) "Special charges";
(n) "Incremental nursing charge
rate";
(o) "All-inclusive
ancillary";
(p) "Pharmacy,"
subcategories "take home drugs," "experimental drugs," and "other
pharmacy";
(q) "IV therapy,"
subcategory "other IV therapy";
(r)
"Medical/surgical supplies and devices," subcategories "take home supplies,"
"prosthetic/orthotic devices," and "oxygen - take home";
(s) "Oncology," subcategory "other
oncology";
(t) "Durable medical
equipment (other than renal)," subcategories "rental," "purchase of new DME,"
"purchase of used DME," "supplies/drugs for DME effectiveness (home health
agency only)," and "other equipment";
(u) "Laboratory," subcategory "other
laboratory";
(v) "Laboratory
pathology," subcategory "other laboratory pathological";
(w) "Radiology - Diagnostic," subcategory
"other radiology - diagnostic";
(x)
"Radiology - Therapeutic and/or chemotherapy administration," subcategory
"other radiology - therapeutic";
(y) "Nuclear medicine," subcategory "other
nuclear medicine";
(z) "CT scan,"
subcategory "other CT scan";
(aa)
"Operating room services," subcategories "organ transplant -other than kidney,"
"kidney transplant," and "other operating room services";
(bb) "Anesthesia," subcategories
"acupuncture" and "other anesthesia";
(cc) "Blood and blood components";
(dd) "Administration, processing and storage
for blood and blood component," subcategory "other processing and
storage";
(ee) "Other imaging,"
subcategory "other imaging service";
(ff) "Respiratory services," subcategory
"other respiratory services";
(gg)
"Physical therapy services," subcategory "other physical therapy";
(hh) "Occupational therapy services,"
subcategory "other occupational therapy";
(ii) "Speech therapy - Language pathology,"
subcategory "other speech-language pathology";
(jj) "Emergency room," subcategories "EMTALA
emergency medical screening services," "ER beyond EMTALA screening" and "other
emergency room";
(kk) "Pulmonary
function," subcategory "other pulmonary function";
(II) "Audiology," subcategory "other
audiology";
(mm) "Cardiology,"
subcategory "other cardiology";
(nn) "Ambulatory surgical care," subcategory
"other ambulatory surgical care";
(oo) "Outpatient services";
(pp) "Clinic," subcategories "chronic pain
center," "psychiatric clinic," "OB-GYN clinic," "pediatric clinic," "urgent
care clinic," and "family practice clinic";
(qq) "Free-standing clinic";
(rr) "Osteopathic services";
(ss) "Ambulance";
(tt) "Home health (HH) - Skilled
nursing";
(uu) "Home health (HH) -
Medical social services";
(vv)
"Home health (HH) - Aide";
(ww)
"Home health (HH) - Other visits";
(xx) "Home health (HH) - Units of
service";
(yy) "Home health (HH) -
Oxygen";
(zz) "Magnetic resonance
technology (MRT)," subcategory "other MRT";
(aaa) "Medical/surgical supplies -
Extension," only subcategory "FDA investigational devices";
(bbb) "Home IV therapy services";
(ccc) "Hospice services";
(ddd) "Respite care";
(eee) "Outpatient special residence
charges";
(fff) "Trauma
response";
(ggg) "Cast room,"
subcategory "other cast room";
(hhh) "Recovery room," subcategory "other
recovery room";
(iii) "Labor
room/delivery," subcategories "circumcision" and "other labor
room/delivery";
(jjj) "EKG/ECG
(Electrocardiogram)," subcategory "other EKG/ECG";
(kkk) "EEG (Electroencephalogram),"
subcategory "other EEG";
(III)
"Gastro-intestinal services," subcategory "other gastro-in-testinal";
(mmm) "Speciality room -
Treatment/observation room," subcategories "general classification" and "other
speciality rooms";
(nnn)
"Preventive care services";
(ooo)
"Telemedicine," subcategory "general classification";
(ppp) "Extra-corporal shock wave therapy
(formerly lithotripsy)," subcategory "other ESWT";
(qqq) "Inpatient renal dialysis";
(rrr) "Acquisition of body components,"
subcategories "unknown donor," "unsuccessful organ search - donor bank
charges," and "other donor";
(sss)
"Hemodialysis - Outpatient or home," subcategories "hemo-dialysis/composite or
other rate," "home supplies," "home equipment," "maintenance one hundred
percent (home)," "support services (home)," and "other outpatient hemodialysis
(home)";
(ttt) "Peritoneal dialysis
- Outpatient or home," subcategories "peritoneal/composite or other rate,"
"home supplies," "home equipment," "maintenance one hundred percent (home),"
"support services (home)," and "other outpatient peritoneal dialysis
(home)";
(uuu) "Continuous
ambulatory peritoneal dialysis (CAPD) - Outpatient or home," subcategories
"CAPD/composite or other rate," "home supplies," "home equipment," "maintenance
one hundred percent (home)," "support services (home)," and "other outpatient
CAPD (home)";
(vvv) "Continuous
cycling peritoneal dialysis (CCPD) - Outpatient or home," subcategories
"CCPD/composite or other rate," "home supplies," "home equipment," "maintenance
one hundred percent (home)," "support services (home)," and "other outpatient
CCPD (home)";
(www) "Miscellaneous
dialysis," subcategories "home dialysis aid visit" and "other miscellaneous
dialysis";
(xxx) "Behavioral health
treatments/services," subcategories "general classification," "milieu therapy,"
"play therapy," "activity therapy," "intensive outpatient services - substance
use disorder (SUD)," and "community behavioral health program (day
treatment)";
(yyy) "Behavioral
health treatment/services (extension)";
(zzz) "Other diagnostic services,"
subcategories "allergy test" and "other diagnostic services";
(aaaa) "Medical rehabilitation day
program";
(bbbb) "Other therapeutic
services - extension," subcategories "recreational therapy," "drug
rehabilitation," "alcohol rehabilitation," "complex medical equipment -
routine," "complex medical equipment - ancillary," "athletic training," and
"kinesiotherapy";
(cccc)
"Professional fees";
(dddd)
"Patient convenience items"; and
(eeee) Revenue code categories and
subcategories that are not identified in this
section.
11-14-075, recodified as §182-550-1500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. 07-14-018, § 388-550-1500, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. 03-19-046, § 388-550-1500, filed 9/10/03, effective 10/11/03. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-1500, filed 12/18/97, effective 1/18/98.
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