Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0050 - Physician-related services definitions

Current through Register Vol. 24-14, July 15, 2024
The following definitions and abbreviations and those found
				  in chapter 182-500 WAC, apply to this chapter.
"Actual acquisition cost"
- See WAC
				  182-530-1050.
"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 multi-disciplinary team at a medicaid agency-approved
				  rehabilitation facility. The program provides 24-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 medicaid 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
				  medicaid 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 medicaid 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. See WAC
				182-530-7900;
(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 website;
(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
				  Med-icaid 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 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 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.