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Provider Notice 12-23

 

Dear provider,

 

Effective for dates of service on and after April 1, 2012, the Medicaid Program of the Health Care Authority (the Agency) will:

 

·                     Update the Outpatient Hospital and Outpatient Prospective Payment System (OPPS) Fee Schedule with added codes and coverage changes;

·                     Update changes in prior authorization requirements for certain Current Procedural Terminology (CPT®) Codes; and

·                     Implement a utilization review program to determine the medical necessity of emergency room (ER) use for conditions that could be treated in a primary care office or urgent care clinic.

 

 

Effective for dates of service on and after April 15, 2012, the Medicaid Program of the Health Care Authority (the Agency) will require prior authorization for a select group of surgical procedure codes.  Qualis Health or the Agency will be conducting the medical necessity review as indicated on the fee schedule.  Submitting requests for medically necessary reviews will begin April 1, 2012.

 

Note:  Updated ASC fee schedules will be posted April 1, 2012.

 

Overview

 

All policies previously published remain the same unless specifically identified as changed in this provider notice.

 

Fee Schedule Changes

 

Added/Changed Procedure Codes

 

The Agency will update the Outpatient Hospital and Outpatient Prospective Payment System (OPPS) Fee Schedule for procedures performed in an outpatient hospital setting. 

Updates to the Outpatient Prospective Payment System (OPPS) and Outpatient Hospital Fee Schedule will be available online at: http://hrsa.dshs.wa.gov/RBRVS

 

Note:   Due to its licensing agreement with the American Medical Association (AMA) regarding the use of CPT codes and descriptions, the Agency publishes only the official brief descriptions for all codes.  Please refer to your current CPT book for full descriptions.


Effective for dates of service on and after April 1, 2012, the Agency will add the following CPT and Healthcare Common Procedure Coding System (HCPCS) procedure codes.  Procedures with a value in the alternate payment method column may be paid using the method listed.

 

Authorization

Procedure Code

Brief Description

Coverage Indicator

Max Units

Alternate Payment Method

 

C9288

Inj, centruroides (scorpion)

1

UR

RCC

 

C9289

Inj, erwinia chrysanthemi

1

UR

RCC

PA

C9290

Inj, bupivacaine liposome

1

UR

RCC

PA

C9291

Injection, aflibercept

1

UR

RCC

 

C9733

Non-ophthalmic FVA

0

NC

 

 

Legend

CPA = Contractor prior authorization (Qualis is the current contractor).

L = Program Limitations, see billing instructions.

PA = Agency Authorization.

R = Program restrictions apply, see program guides.

RCC = Paid ratio of cost to charge when APC payment method does not apply.

UR = Under review.

 

Retroactive to dates of service on and after January 1, 2012, the Agency changed the following procedure codes from noncovered to covered.  Procedures with a value in the alternate payment method column may be paid using the payment method listed. The Agency will adjust claims for these services.

 

 

Authorization

Procedure Code

Brief Description

Coverage Indicator

Max Units

Alternate Payment Method

 

64633

Destroy cerv/thor facet jnt

1

1

RCC

 

64634

Destroy c/th facet jnt addl

1

UR

RCC

 

64635

Destroy lumb/sac facet jnt

1

1

RCC

 

64636

Destroy l/s facet jnt addl

1

UR

RCC

 


Effective for dates of service on and after April 1, 2012, the Agency will change the following CPT® codes from noncovered to covered.  Procedures with a value in the alternate payment method column may be paid using that method.

 

Prior Authorization Requirement

Procedure Code

Brief Description

Coverage Indicator

Max Units

Alternate Payment Method

 

62369

Anal sp inf pmp/reprg&fill

1

1

RCC

 

62370

Anl sp inf pmp/mdreprg&fil

1

1

RCC

PA

J0490

Belimumab injection

1

UR

RCC

 

 

Effective for dates of service on and after April 1, 2012, the Agency will change the following CPT® codes from covered to noncovered in an outpatient setting:

 

HCPCS

Brief Description

92071

Contact lens fitting for tx

92072

Fit contac lens for managmnt

 

Authorization Requirement Changes

 

Effective for dates of service on and after April 15, 2012, the following CPT codes require providers to submit PA requests via Qualis Health rather than directly to the Agency:

 

Authorization

HCPCS

Brief Description

L/CPA

22633

Lumbar spine fusion combined

L/CPA

22634

Spine fusion extra segment

L/CPA

22856

Cerv artific diskectomy

L/CPA

22857

Lumbar artif diskectomy

L/CPA

22861

Revise cerv artific disc

L/CPA

22862

Revise lumbar artif disc

L/CPA

22865

Remove lumb artif disc

L/CPA

29877

Knee arthroscopy/surgery

 

 


Effective for dates of service on and after April 15, 2012, the Agency will require PA for the following CPT® codes:

 

Authorization

HCPCS

Brief Description

PA/EPA

58150

Total hysterectomy

PA/EPA

58152

Total hysterectomy

PA/EPA

58180

Partial hysterectomy

PA/EPA

58260

Vaginal hysterectomy

PA/EPA

58262

Vag hyst including t/o

PA/EPA

58263

Vag hyst w/t/o & vag repair

PA/EPA

58267

Vag hyst w/urinary repair

PA/EPA

58270

Vag hyst w/enterocele repair

PA/EPA

58275

Hysterectomy/revise vagina

PA/EPA

58280

Hysterectomy/revise vagina

PA/EPA

58285

Extensive hysterectomy

PA/EPA

58290

Vag hyst complex

PA/EPA

58291

Vag hyst incl t/o complex

PA/EPA

58292

Vag hyst t/o & repair compl

PA/EPA

58293

Vag hyst w/uro repair compl

PA/EPA

58294

Vag hyst w/enterocele compl

PA/EPA

58541

Lsh uterus 250 g or less

PA/EPA

58542

Lsh w/t/o ut 250 g or less

PA/EPA

58543

Lsh uterus above 250 g

PA/EPA

58544

Lsh w/t/o uterus above 250 g

PA/EPA

58545

Laparoscopic myomectomy

PA/EPA

58546

Laparo-myomectomy complex

PA/EPA

58550

Laparo-asst vag hysterectomy

PA/EPA

58552

Laparo-vag hyst incl t/o

PA/EPA

58553

Laparo-vag hyst complex

PA/EPA

58554

Laparo-vag hyst w/t/o compl

PA/EPA

58570

tlh uterus 250

PA/EPA

58571

tlh w/t/o 250

 

 

Utilization Review to Determine Medical Necessity of Emergency Room Use

 

Effective for dates of service on and after April 1, 2012, the Agency will implement a utilization review program to determine the medical necessity of emergency room (ER) use for conditions that can be treated in a primary care office or urgent care clinic.  Claims submitted for these conditions will be denied.  The Agency has worked with ER physicians and other providers to develop expedited prior authorization (EPA) criteria that will allow the emergency room physician to certify the use of the emergency room setting as medically necessary to treat one of these conditions due to extenuating clinical circumstances.  Efforts are being made to establish processes for primary care and urgent care referrals.  The Agency will continue to pay for visits to the emergency department when it determines the ER setting was the medically necessary place of service for the care.  The Agency will make available an updated list of Frequently Asked Questions, the Expedited Prior Authorization Criteria and other tools at: http://hrsa.dshs.wa.gov/authorization/

 


Authorization Requirements for Surgical Procedures

 

Changes in Authorization Requirements for Certain Surgical Procedures

 

Effective for dates of service on and after April 15, 2012, the Agency is expanding its prior authorization requirements to include selected surgical procedures.  The medical necessity review for these procedures will be conducted by the Agency or Qualis Health.

 

For more information about submitting medical necessity request reviews, go online at: Surgical Reviews.  These reviews can be submitted starting April 1, 2012.

 

The Agency and Qualis Health have contracted to provide web-based access for utilization review and prior authorization (PA) for surgeries in the following categories:

 

·                     Spinal,

·                     Major joints,

·                     Upper and lower extremities,

·                     Carpal tunnel release, and

·                     Thoracic outlet release

 

Qualis Health conducts the review of the request to establish medical necessity for surgeries, but does not issue authorizations. Qualis Health forwards its recommendations to the Agency for final authorization determination

 

Surgical services require Agency authorization regardless of place of service or when performed as:

 

·                     Urgent;

·                     An emergency; or

·                     A scheduled surgery.

 

The Agency allows five business days for providers to submit retrospective authorization requests to Qualis Health for surgical procedures performed as urgent or emergency procedures.

 

The Agency will require prior authorization on some procedures that will not be reviewed by Qualis Health.  These reviews will continue to be conducted by the Agency.  Please check the OPPS fee schedule online at: Outpatient Fee Schedule, go to “O” for outpatient.  The specific review requirements will be available online April 1, 2012.

 

BC/AD

Provider Publications Team

The Medicaid Program of the Health Care Authority

 

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