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

Current through Register Vol. 24-14, July 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.