Outpatient Rehabilitation Billing Guide
Washington Apple Health (Medicaid)OutpatientRehabilitationBilling GuideJanuary 1, 2021
DisclaimerEvery effort has been made to ensure this guide’s accuracy. If an actual orapparent conflict between this document and a Health Care Authority rule arises,the rule applies.Billing guides are updated on a regular basis. Due to the nature of contentchange on the internet, we do not fix broken links in past guides. If you find abroken link, please check the most recent version of the guide. If this is the mostrecent guide, please notify us at askmedicaid@hca.wa.gov.About this guide *This publication takes effect January 1, 2021, and supersedes earlier billingguides to this program. Unless other specified, the program in this guide isgoverned by the rules found in WAC 182-545-200.The Health Care Authority is committed to providing equal access to our services.If you need an accommodation or require documents in another format, pleasecall 1-800-562-3022. People who have hearing or speech disabilities, please call711 for relay services.Washington Apple Health means the public health insuranceprograms for eligible Washington residents. Washington AppleHealth is the name used in Washington State for Medicaid, thechildren’s health insurance program (CHIP), and state-onlyfunded health care programs. Washington Apple Health isadministered by the Washington State Health Care Authority.Refer also to HCA’s ProviderOne billing and resource guide for valuableinformation to help you conduct business with the Health Care Authority.Services and equipment related to the programs listed below are not covered bythis billing guide and must be billed using their program-specific billing guide: Home health services Neurodevelopmental centers Wheelchairs, durable medical equipment, and supplies Prosthetic/orthotic devices and supplies Outpatient hospital services Physician-related services/healthcare professional services (includesaudiology)*This publication is a billing instruction.CPT codes and descriptions only are copyright 2020 American Medical Association.2 OUTPATIENT REHABILITATION BILLING GUIDE
How can I get HCA Apple Health provider documents?To access provider alerts, go to HCA’s provider alerts webpage.To access provider documents, go to HCA’s provider billing guides and feeschedules webpage.Where can I download HCA forms?To download an HCA form, see HCA’s Forms & Publications webpage. Type onlythe form number into the Search box (Example: 13-835).Copyright disclosureCurrent Procedural Terminology (CPT) copyright 2020 American MedicalAssociation (AMA). All rights reserved. CPT is a registered trademark of the AMA.Fee schedules, relative value units, conversion factors and/or related componentsare not assigned by the AMA, are not part of CPT, and the AMA is notrecommending their use. The AMA does not directly or indirectly practicemedicine or dispense medical services. The AMA assumes no liability for datacontained or not contained herein.What has changed?SubjectChangeReason for ChangeEntire GuideHousekeepingchangesTo improve usability andclarityCoverage tableAdded CPT codes96112 and 96113To clarify code coveragefor qualified providertypes under e Services FeeScheduleCPT codes and descriptions only are copyright 2020 American Medical Association.3 OUTPATIENT REHABILITATION BILLING GUIDE
Table of ContentsResources Available. 6Client Eligibility. 8How do I verify a client’s eligibility? . 8Verifying eligibility is a two-step process: . 8Are clients enrolled in an HCA-contracted managed care organization (MCO)eligible? . 9Managed care enrollment . 9Clients who are not enrolled in an HCA-contracted managed care plan forphysical health services . 10Integrated managed care . 10Integrated Apple Health Foster Care (AHFC) . 11Fee-for-service Apple Health Foster Care . 11What if a client has third-party liability (TPL)? . 11Provider Eligibility . 12Who may provide outpatient rehabilitation services? . 12Coverage . 13When does the Health Care Authority pay for outpatient rehabilitation? . 13Telemedicine and Coronavirus (COVID-19) . 13What outpatient rehabilitation does the Health Care Authority cover forclients age 20 and younger? . 14Which clients receive short-term outpatient rehabilitation coverage? . 14What clinical criteria must be met for the short-term outpatientrehabilitation benefit? . 14What are the short-term outpatient rehabilitation benefit limits? . 15Occupational therapy . 16Physical therapy . 20Speech therapy . 24Swallowing evaluations . 27Using timed and untimed procedure codes . 27What are habilitative services under this program? . 27How do I bill for habilitative services? . 27Coverage Table . 28Where can I find the fee schedule? . 35Authorization . 36What are the general guidelines for authorization? . 36CPT codes and descriptions only are copyright 2020 American Medical Association.4 OUTPATIENT REHABILITATION BILLING GUIDE
How can I request additional units for clients age 21 and older, and clientsage 19 through 20 in MCS? . 36Expedited Prior Authorization. 36How can I request a limitation extension (LE)? . 37Billing . 38Are referring provider NPIs required on all claims? . 38How do I bill claims electronically? . 38Are modifiers required for billing? . 38What are the general billing requirements? . 39Home health agencies . 40Outpatient hospital or hospital-based clinic setting . 40CPT codes and descriptions only are copyright 2020 American Medical Association.5 OUTPATIENT REHABILITATION BILLING GUIDE
Resources AvailableTopicResourceBecoming a provider or submitting achange of address or ownershipSee the Health Care Authority’s Billers,providers, and partners webpageFinding out about payments, denials,claims processing, or HCA managedcare organizationsSee the Health Care Authority’s Billers,providers, and partners webpageElectronic billingSee the Health Care Authority’s Billers,providers, and partners webpageFinding HCA documents, (e.g., billingguides, provider notices, fee schedules)See the Health Care Authority’s Billers,providers, and partners webpagePrivate insurance or third-partyliabilitySee the Health Care Authority’s Billers,providers, and partners webpageHow do I check how many units oftherapy the client has remaining?Providers may contact HCA’s MedicalAssistance Customer Service Center(MACSC) via: Telephone toll-free at (800) 562-3022or Web form or emailCPT codes and descriptions only are copyright 2020 American Medical Association.6 OUTPATIENT REHABILITATION BILLING GUIDE
TopicResourceHow do I obtain prior authorization ora limitation extension?Providers may submit their requests onlineor by submitting the request in writing.See HCA’s prior authorization webpagefor details.Written requests for prior authorization orlimitation extensions must include: A completed, typed GeneralInformation for Authorization (HCA 13835 form). This request form must bethe cover page when you submit yourrequest. A completed Outpatient RehabilitationAuthorization Request (HCA 13-786form) and all the documentation listedon that form and any other medicaljustification.Fax your request to: (866) 668-1214. Forinformation about downloading HCAforms, see Where can I download HCAforms?General definitionsSee chapter 182-500 WACWhere do I find HCA’s maximumallowable fees for services?See the Health Care Authority’s FeeSchedulesCPT codes and descriptions only are copyright 2020 American Medical Association.7 OUTPATIENT REHABILITATION BILLING GUIDE
Client EligibilityMost Apple Health clients are enrolled in an HCA-contracted managed careorganization (MCO). This means that Apple Health pays a monthly premium to anMCO for providing preventative, primary, specialty, and other health services toApple Health clients. Clients in managed care must see only providers who are intheir MCO’s provider network, unless prior authorized or to treat urgent oremergent care. See HCA’s Apple Health managed care page for further details.It is important to always check a client’s eligibility prior toproviding any services because it affects who will pay for theservices.How do I verify a client’s eligibility?Check the client’s services card or follow the two-step process below to verifythat a client has Apple Health coverage for the date of service and that theclient’s benefit package covers the applicable service. This helps preventdelivering a service HCA will not pay for.Verifying eligibility is a two-step process:Step 1.Verify the patient’s eligibility for Apple Health. For detailedinstructions on verifying a patient’s eligibility for Apple Health,see the Client Eligibility, Benefit Packages, and Coverage Limitssection in HCA’s ProviderOne Billing and Resource Guide.If the patient is eligible for Apple Health, proceed to Step 2. Ifthe patient is not eligible, see the note box below.Step 2.Verify service coverage under the Apple Health client’sbenefit package. To determine if the requested service is acovered benefit under the Apple Health client’s benefit package,see HCA’s Program Benefit Packages and Scope of Serviceswebpage.Note: Patients who are not Apple Health clients may submit an application forhealth care coverage in one of the following ways:1.By visiting the Washington Healthplanfinder’s website.2.By calling the Customer Support Center toll-free at: 855-WAFINDER(855-923-4633) or 855-627-9604 (TTY)3.By mailing the application to: Washington Healthplanfinder, PO Box 946,Olympia, WA 98507In-person application assistance is also available. To get information about inperson application assistance available in their area, people may visit theWashington Healthplanfinder’s website or call the Customer Support Center.CPT codes and descriptions only are copyright 2020 American Medical Association.8 OUTPATIENT REHABILITATION BILLING GUIDE
Are clients enrolled in an HCA-contracted managedcare organization (MCO) eligible?Yes. Most Medicaid-eligible clients are enrolled in one of HCA’s contractedmanaged care organizations (MCOs). For these clients, managed care enrollmentwill be displayed on the client benefit inquiry screen in ProviderOne.All medical services covered under an HCA-contracted MCO must be obtained bythe client through designated facilities or providers. The MCO is responsible for: Payment of covered services Payment of services referred by a provider participating with the plan to anoutside providerNote: A client’s enrollment can change monthly. Providers whoare not contracted with the MCO must receive approval fromboth the MCO and the client’s primary care provider (PCP) priorto serving a managed care client.Send claims to the client’s MCO for payment. Call the client’s MCO to discusspayment prior to providing the service. Providers may bill clients only in verylimited situations as described in WAC 182-502-0160.Managed care enrollmentApple Health (Medicaid) places clients into an HCA-contracted MCO the samemonth they are determined eligible for managed care as a new or renewingclient. This eliminates a person being placed temporarily in FFS while they arewaiting to be enrolled in an MCO or reconnected with a prior MCO. Thisenrollment policy also applies to clients in FFS who have a change in the programthey are eligible for. However, some clients may still start their first month ofeligibility in the FFS program because their qualification for MC enrollment is notestablished until the month following their Medicaid eligibility determination.New clients are those initially applying for benefits or those with changes in theirexisting eligibility program that consequently make them eligible for AppleHealth managed care.Checking eligibility Providers must check eligibility and know when a client is enrolled and withwhich MCO. For help with enrolling, clients can refer to the WashingtonHealthplanfinder’s Get Help Enrolling page. MCOs have retroactive authorization and notification policies in place. Theprovider must know the MCO’s requirements and be compliant with theMCO’s policies.Clients have a variety of options to change their plan: Available to clients with a Washington Healthplanfinder account:Go to Washington HealthPlanFinder website.CPT codes and descriptions only are copyright 2020 American Medical Association.9 OUTPATIENT REHABILITATION BILLING GUIDE
Available to all Apple Health clients:oVisit the ProviderOne Client Portal website:oCall Apple Health Customer Service at 1-800-562-3022. The automatedsystem is available 24/7.oRequest a change online at ProviderOne Contact Us (this will generatean email to Apple Health Customer Service). Select the topic“Enroll/Change Health Plans.”For online information, direct clients to HCA’s Apple Health Managed Carewebpage.Clients who are not enrolled in an HCA-contractedmanaged care plan for physical health servicesSome Medicaid clients do not meet the qualifications for managed careenrollment. These clients are eligible for services under the FFS Medicaidprogram. In this situation, each Integrated Managed Care (IMC) plan will haveBehavioral Health Services Only (BHSO) plans available for Apple Health clientswho are not in managed care. The BHSO covers only behavioral health treatmentfor those clients. Clients who are not enrolled in an HCA-contracted managedcare plan are automatically enrolled in a BHSO with the exception of AmericanIndian/Alaska Native clients. Some examples of populations that may be exemptfrom enrolling into a managed care plan are Medicare dual-eligible, AmericanIndian/Alaska Native, Adoption support and Foster Care alumni.Integrated managed careClients qualified for managed care enrollment will receive all physical healthservices, mental health services, and substance use disorder treatment throughtheir HCA-contracted managed care organization (MCO).American Indian/Alaska Native (AI/AN) clients have twooptions for Apple Health coverage:-Apple Health Managed Care; or-Apple Health coverage without a managed care plan (alsoreferred to as fee-for-service [FFS])If a client does not choose an MCO, they will be automaticallyenrolled into Apple Health FFS for all their health care services,including comprehensive behavioral health services. See theHealth Care Authority’s (HCA) American Indian/Alaska Nativewebpage.CPT codes and descriptions only are copyright 2020 American Medical Association.10 OUTPATIENT REHABILITATION BILLING GUIDE
For more information about the services available under the FFSprogram, see HCA’s Mental Health Services Billing Guide andthe Substance Use Disorder Billing Guide.For full details on integrated managed care, see HCA’s Apple Health managedcare webpage and scroll down to “Changes to Apple Health managed care.”Integrated Apple Health Foster Care (AHFC)Children and young adults in the Foster Care, Adoption Support and Alumniprograms who are enrolled in Coordinated Care of Washington’s (CCW) AppleHealth Foster Care program receive both medical and behavioral health servicesfrom CCW.Clients under this program are: Under the age of 21 who are in foster care (out of home placement) Under the age of 21 who are receiving adoption support Age 18-21 years old in extended foster care Age 18 to 26 years old who aged out of foster care on or after their 18thbirthday (alumni)These clients are identified in ProviderOne as “Coordinated CareHealthy Options Foster Care.”The Apple Health Customer Services staff can answer general questions aboutthis program. For specific questions about Adoption Support, Foster Care orAlumni clients, contact HCA’s Foster Care Medical Team at 1-800-562-3022, Ext.15480.Fee-for-service Apple Health Foster CareChildren and young adults in the fee-for-service Apple Health Foster Care,Adoption Support and Alumni programs receive behavioral health servicesthrough the regional Behavioral Health Services Organization (BHSO). For details,see HCA’s Mental Health Services Billing Guide, under How do providers identifythe correct payer?What if a client has third-party liability (TPL)?If the client has third-party liability (TPL) coverage (excluding Medicare), priorauthorization must be obtained before providing any service requiring priorauthorization. For more information on TPL, refer to HCA’s ProviderOne Billingand Resource Guide.CPT codes and descriptions only are copyright 2020 American Medical Association.11 OUTPATIENT REHABILITATION BILLING GUIDE
Provider EligibilityWho may provide outpatient rehabili
Jan 01, 2021 · CPT codes and descriptions only are copyright 2020 American Medical Association. 2 OUTPATIENT REHABILITATION BILLING GUIDE Disclaimer Ev
5. The batch will close and so will the OPIE Billing application. 6. To return to OPIE Billing, create a new batch. Get Started in Billing - Set up Global Settings in Billing Admin Rights in OPIE are required to access Billing Settings. 1. Log into OPIE Billing, go to the top left part of the Window to the menus: File, Windows, Help and click .
Consolidated Billing 3 Medicare Part B 3. SNF Billing Requirements 4. Billing Tips 5 Special Billing Situations 6 Readmission Within 30 Days 6 Benefits Exhaust 7 No Payment Billing 8 Expedited Review Results. 9 Noncovered Days 10 Other SNF Billing Situations 10. Resources 12. The American Hospital Association (the " AHA
HOSPITAL BILLING OVERVIEW The Ohio Department of Medicaid (ODM) Hospital Billing Guidelines contain basic billing information for Ohio Medicaid hospital providers regarding inpatient and outpatient claims. It is intended to be a su pplemental guide to assist providers with specific Medicaid policy from a billing
2. What is the difference between outpatient and inpatient coding? Answer: Outpatient coders will focus on learning CPT , HCPCS Level II, and ICD-9-CM codes volumes 1 and 2. They will work in physician offices, outpatient clinics, and facility outpatient departments. Outpatient facility coders will also work with Ambu-
The process for an AIA billing in Foundation has a few basic steps: 1. Create an AIA billing record 2. Create a schedule of values for Application 1 3. Print and post the application 4. Repeat as needed 5. Release retainage Create an AIA Billing Record Setting up an overall billing record for your progress billing job in Foundation means two .
Services Billing Guide; reorganized section Added "hip surgery for femoroacetabular impingement syndrome" to the list of services under "Surgical and medical procedures and evaluations" To remove redundancy between billing guides and improve clarity To correct an oversight This publication is a billing instruction.
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CCSS Checklist—Grade 2 Writing 1 Teacher Created Resources Writing Text Types and Purposes Standard Date Taught Date Retaught Date Assessed Date Reassessed Notes ELA-Literacy.W.2.1 Write opinion pieces in which they introduce the topic or book they are writing about, state an opinion, supply reasons that support the opinion, use linking words (e.g., because, and, also) to connect opinion and .
