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DEPARTMENT OF SOCIAL AND HEALTH SERVICES HEALTH AND RECOVERY SERVICES ADMINISTRATION Olympia, Washington To: All Hospitals Managed Care Organizations Douglas Porter, Assistant Secretary Health and Recovery Services Administration (HRSA) Memo #: 08-42 Issued: June 30, 2008 For information, contact: (800) 562-3022, option 2, or go to: http://maa.dshs.wa.gov/contact/prucontact.asp

From:

Subject: Hospitals: Program and Fee Schedule Updates Effective for dates of service on and after July 1, 2008, the Health and Recovery Services Administration (HRSA) will: · · · · · · Implement Current Procedural Terminology (CPT®) and Healthcare Common Procedural Coding System (HCPCS) code updates; Implement injectable drug updates; Implement Revenue Code updates; Update the HRSA-Approved Sleep Study Centers (Centers of Excellence) provider list; Update the HRSA-Approved Organ Transplant Centers of Excellence provider list; and Implement National Drug Code (NDC) requirement changes.

Fee Schedules

Visit HRSA's web site at http://maa.dshs.wa.gov/RBRVS/Index.html to view the new fee schedule, effective July 1, 2008. Bill HRSA your usual and customary charge.

Policy Updates

All procedures performed in an outpatient hospital are subject to the parent program guidelines. For example: Surgeries and therapies are subject to the Physician-Related Services Washington Administrative Code (WAC) and Billing Instructions; dental procedures are subject to the Dental-Related Services WAC and Billing Instructions.

CPT® is a trademark of the American Medical Association. Current Procedural Terminology© 2007 American Medical Association. All Rights Reserved.

Memo # 08-42 June 30, 2008 Page 2 Effective for dates of service on and after July 1, 2008, HRSA will add outpatient coverage for the following procedure codes: Procedure Code 11921 33249 C9237 C9240 C9241 J7602 J7603 Q4098 Coverage Indicator 1 1 1 1 1 1 1 1

Auth L N/A N/A N/A N/A N/A N/A N/A

Effective for dates of service on and after July 1, 2008, HRSA will no longer cover code J2315. HRSA is clarifying the coverage and payment for the following procedure codes. The procedure codes have been covered since July 1, 2007; however, the outpatient fee was inadvertently removed from the fee schedule. Procedure Code 94644 94645 Coverage Indicator 1 1 Outpatient Fee $22.01 $8.25

Auth N/A N/A

Legend A B L = Covered for Ambulatory Payment Classification (APC)-paid hospitals (OPPS) only. = Covered for non-OPPS and critical access hospitals (CAH) only. = The use of this procedure code may have certain limitations or restrictions (e.g., ages, authorization requirements, diagnosis, or facilities). Please see the program specific publications for details prior to providing this service. 1 = Covered, all hospitals paid in accordance with each hospital's specific methodology. PA = Prior Authorization. EPA = Expedited Prior Authorization

Deleted Codes

Effective for dates of service on or after July 1, 2008, in accordance with the Centers for Medicare and Medicaid Services (CMS), HRSA is deleting procedure code G0377 from the outpatient fee schedule.

Current Procedural Terminology© 2007 American Medical Association. All Rights Reserved.

Memo # 08-42 June 30, 2008 Page 3

Authorization Changes

Effective for dates of service on and after July 1, 2008, HRSA either requires authorization or has limits on coverage for the following procedures codes when billed on a hospital claim (UB04): Type of Prior Authorization Required *L *L *L

Procedure Code 83655 J2323 J3487

Brief Description Assay of lead Natalizumab injection Zoledronic acid

HRSA is clarifying the authorization requirement for the following procedure code. The EPA requirement has been in effect since January 1, 2006. Type of Prior Authorization Required EPA**

Procedure Code C1300

Brief Description HYPERBARIC Oxygen

Effective for dates of service on and after July 1, 2008, HRSA will no longer require PA for the following CPT and HCPCS codes: Procedure Coverage Code Indicator C1820 A 40720 1 76814 1

Auth N/A N/A N/A

Legend ** A B 1 *L See HRSA's Physician-Related Services Billing Instructions for EPA criteria. Covered for APC-paid hospitals (OPPS) only. Covered for non-OPPS and critical access hospitals (CAH) only. Covered for all hospitals paid in accordance with each hospital's specific methodology. = The use of this procedure code may have certain limitations or restrictions (e.g., ages, authorization requirements, diagnosis, or facilities). Please see the program specific publications for details prior to providing this service. = Prior Authorization. = Expedited Prior Authorization = = = =

PA EPA

Current Procedural Terminology© 2007 American Medical Association. All Rights Reserved.

Memo # 08-42 June 30, 2008 Page 4

Injectable Drug Updates

HRSA updates the maximum allowable fees for injectable drugs on a quarterly basis. Current and past fee schedules are posted on HRSA's website at http://maa.dshs.wa.gov/RBRVS/index.html. All fees have been updated at 106% of the average sales price (ASP) as defined by Medicare. If a Medicare fee is unavailable for a particular drug, HRSA prices the drug at 86% of the Average Wholesale Price (AWP). Effective for dates of service on and after July 1, 2008, HRSA has added the following procedure codes to the list of procedures payable by maximum allowable fee when the APC payment is not applicable. See the Outpatient Hospital Fee Schedule for a complete list of all coverage decisions. Coverage Decision 1 1 Procedure Code Q4096 Q4097 Procedure Code Descriptions VWF complex, not Humate-P Inj IVIG Privigen 500 mg

Modifiers

HRSA follows the Correct Coding Initiative guidelines with regards to the use of modifiers. Currently (July 2008), the following modifiers, as defined by CPT, are the only modifiers approved for outpatient use: 25 27 50 52 58 59 73 74 76 77 78 79 91 CA E1 E2 E3 E4 F1 F2 F3 F4 F5 F6 F7 F8 F9 FA GA GG GH LC LD LT QM QN RC RT T1 T2 T3 T4 T5 T6 T7 T8 T9 TA

Note: The inappropriate use of modifiers may result in claim line denials.

Current Procedural Terminology© 2007 American Medical Association. All Rights Reserved.

Memo # 08-42 June 30, 2008 Page 5

Revenue Code Table Update

HRSA has updated the revenue code table as follows: Revenue Code 0634 0635 0636 0637 "OP" previous REQ REQ REQ REQ Legend NDC = OP = REQ = National Drug Code Outpatient Hospital CPT/HCPCS Required

"OP" now NDC-REQ NDC-REQ NDC-REQ NDC-REQ

Neonate Revenue Code Definitions

HRSA has defined six levels of care for newborns and correlates each level to the nursery accommodation revenue codes. The billed accommodation revenue code must meet the associated level of care criteria and be supported by documentation in the medical record. REV REV CODE CODE DESCRIPTION 0170 General Classification Nursery

LEVEL OF CARE

Normal Newborn Care Normal healthy newborns with low complexity needs are physiologically stable and are rooming with mom. InterQual Newborn Level I criteria; American Academy of Pediatrics Level I

Current Procedural Terminology© 2007 American Medical Association. All Rights Reserved.

Memo # 08-42 June 30, 2008 Page 6 REV REV CODE CODE DESCRIPTION 0171 Newborn ­ Level I

LEVEL OF CARE Level I Nursery/General Nursery Observation

Healthy newborns (birth weight > 2000 gms. or gestational age > 35 wks.) with low complexity needs and who are physiologically stable and require routine evaluation and observation during the immediate post-partum period. Examples of care at this level are: · · · · · Routine bilirubin and blood glucose monitoring; Initiation of phototherapy < 2 days, drug withdrawal management new or continued from higher level and NAS score 1-8; Isolette/warmer for thermoregulation of neonates > 35 weeks gestation; Diagnostic work-up/surveillance on otherwise stable neonate; and Services rendered to growing premature infant without supplemental oxygen or IV needs.

0172

Newborn ­ Level II

InterQual Newborn Level I criteria; American Academy of Pediatrics Level I and some Level IIA guidelines Level II Special Care Nursery/Neonatal Intermediate Care Newborns (birth weight < 2000 gms. or gestational age < 35 wks.) with moderately complex care needs or with physiological immaturity (apnea of prematurity, inability to maintain body temperature, or inability to take oral feedings) combined with medical instabilities. Examples of care at this level are: · · · · · · · IV heplock meds; IV fluids; Supplemental oxygen via hood or nasal cannula of less than 40%; or Feeding via NG, OG, NJ or gastrostomy tube; intensive phototherapy; Drug withdrawal therapy and NAS score >8; Non-invasive hemodynamic monitoring; Continuous monitoring of apnea/bradycardia that requires tactile stimulation or periodic oxygen; and Sepsis evaluation and treatment.

InterQual Special Care Level II criteria; American Academy of Pediatrics Level IIA guidelines

Current Procedural Terminology© 2007 American Medical Association. All Rights Reserved.

Memo # 08-42 June 30, 2008 Page 7 REV REV CODE CODE DESCRIPTION 0173 Newborn ­ Level III

LEVEL OF CARE Level III Neonatal Intensive Care

Newborns (birth weight < 1500 gms., or gestational age < 32 weeks, or hemodynamically unstable) with complex medical conditions that require invasive therapies. Examples of care at this level are: · · · · · · · · · · Supplemental oxygen via hood or nasal cannula of greater than 40%; Intubation with mechanical ventilation; IV pharmacologic treatment for apnea and/or bradycardic episodes; Services for apnea or other conditions requiring assisted respiration; Positive pressure ventilatory assistance; Exchange transfusion, partial or complete; Central or peripheral hyperalimentation; Chest tube; IV bolus or continuous drip therapy for severe physiologic or metabolic instability; and Maintenance of umbilical artery catheters (UACs), peripheral artery catheters (PACs), umbilical vein catheters (UVCs), and/or central vein catheters (CVCs).

0174

Newborn ­ Level IV

InterQual Neonatal Intensive Care Level III criteria; American Academy of Pediatrics Level IIB/IIIA guidelines Level IV Neonatal Intensive Care Newborns with complex medical conditions that meet Level III criteria and require: · · · Extracorpeal membrane oxygenation (ECMO); High frequency ventilation;and Nitric oxide (NO) or complex pre-surgical/surgical interventions for severe congenital malformations or acquired conditions that require use of advanced technology and support.

InterQual Neonatal Intensive Care Level III criteria; American Academy of Pediatrics Level IIIB/IIIC/IIID guidelines

Current Procedural Terminology© 2007 American Medical Association. All Rights Reserved.

Memo # 08-42 June 30, 2008 Page 8 REV REV CODE CODE DESCRIPTION 0179 Other Nursery

LEVEL OF CARE

Transitional Care Newborns with low complexity care needs who are awaiting finalization of discharge plan to home or transfer to a lesser care setting and are hemodynamically stable, in an open crib, and gaining weight. Some examples of appropriate treatments in this level of care that are planned to be continued in the home or lesser care setting are: · · · · · · IV anti-infective administration; Apnea or bradycardia monitoring; Drug withdrawal therapy; Oxygen therapy; Tube feedings < 50% of daily caloric requirement; and Parent or caregiver discharge teaching.

InterQual Transitional Care Nursery criteria

Updates to the HRSA-Approved Sleep Study Centers (Centers of Excellence) Provider List

HRSA has added the following Sleep Centers to the HRSA-Approved Sleep Study Centers of Excellence provider list: Name Auburn Regional Medical Ctr, Inc St. Anthony's Sleep Disorder Center Location ARMC Sleep Apnea Laboratory Gig Harbor Effective Date 4/25/2008 6/4/2008 Term Date 4/13/2013 9/28/2012

HRSA has deleted the following Sleep Center from the HRSA Sleep Center of Excellence list: Name Swedish Sleep Medicine Institute Location Providence Swedish or Swedish First Hill Seattle, WA Term Date 4/1/2008

Current Procedural Terminology© 2007 American Medical Association. All Rights Reserved.

Memo # 08-42 June 30, 2008 Page 9

Updates to the HRSA-Approved Organ Transplant Centers of Excellence Provider List

Approved Transplant Hospital Providence Portland Medical Center Organ(S) PSC-T (Autologous Only) CPT Codes 38206, 38241 Effective Date 6/1/2008

UB-04 Claim Form Billing Requirement Change

As an interim measure, at the request of hospitals, on paper claims using the UB-04, HRSA will accept the 11-digit NDC(s) in form locator 43 (Rev Code Description).

Sterilizations ­ Exception to Rule

Sterilizations require a properly signed consent form. If you do not have one on file when the client is admitted for a delivery, but the client states she has signed a consent form or if another physician is performing the surgery, then complete another sterilization consent form entering the date it was completed. Then submit both consent forms with your claim. If you do not have a properly signed consent form, and your claim was denied, you can submit a request for exception to policy for consideration of payment. Complete the Fax/Written Request Basic Information Form, DSHS 13-756, and explain why the consent was not signed properly. Fax the completed form to the Medical Request Coordinator at (360) 586-1471. Include a copy of the consent form and a copy of the UB-04 claim form.

New Billing Instructions

HRSA is in the process of developing new Outpatient Hospital Services Billing Instructions. See "How can I get HRSA's provider documents?" for information on obtaining these new billing instructions. Watch for the new publication at the following address: http://maa.dshs.wa.gov/download/BI.html

How do I conduct business electronically with HRSA?

You may conduct business electronically with HRSA by accessing the WAMedWeb at http://wamedweb.acs-inc.com.

Current Procedural Terminology© 2007 American Medical Association. All Rights Reserved.

Memo # 08-42 June 30, 2008 Page 10

How can I get HRSA's provider documents?

To obtain DSHS/HRSA provider numbered memoranda and billing instruction, go to the DSHS/HRSA website at http://hrsa.dshs.wa.gov (click the Billing Instructions and Numbered Memorandum link). These may be downloaded and printed.

Current Procedural Terminology© 2007 American Medical Association. All Rights Reserved.

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