PDFWAC 182-550-1400
Covered and noncovered revenue codes categories and subcategories for inpatient hospital services.
Subject to the limitations and restrictions listed, this section identifies covered and noncovered revenue code categories and subcategories for inpatient hospital services.
(1) The medicaid agency pays for an inpatient hospital covered service in the following revenue code categories and subcategories when the hospital provider accurately bills:
(a) "Room & board - Private (one bed)," only subcategories "general classification," "medical/surgical/gyn," "OB," "pediatric," and "oncology";
(b) "Room & board - Semi-private (two bed)," only subcategories "general classification," "medical/surgical/gyn," "OB," "pediatric," and "oncology";
(c) "Room & board - Semi-private - (three and four beds)," only subcategories "general classification," "medical/surgical/gyn," "OB," "pediatric," and "oncology";
(d) "Room & board - Deluxe private," only subcategories "general classification," "medical/surgical/gyn," "OB," "pediatric," and "oncology";
(e) "Nursery," only subcategories "general classification," "newborn - level I," "newborn - level II," "newborn - level III," and "newborn - level IV";
(f) "Intensive care unit," only subcategories "general classification," "surgical," "medical," "pediatric," "intermediate ICU," "burn care," and "trauma";
(g) "Coronary care unit," only subcategories "general classification," "myocardial infarction," "pulmonary care," and "intermediate CCU";
(h) "Pharmacy," only subcategories "general classification," "generic drugs," "nongeneric drugs," "drugs incident to other diagnostic services," "drugs incident to radiology," "nonprescription," and "IV solutions";
(i) "IV therapy," only subcategories "general classification," "infusion pump," "IV therapy/pharmacy services," "IV therapy/drug/supply delivery" and "IV therapy/supplies";
(j) "Medical/surgical supplies and devices," only subcategories "general classification," "nonsterile supply," "sterile supply," "pacemaker," "intraocular lens," and "other implant";
(k) "Oncology," only subcategory "general classification";
(l) "Laboratory," only subcategories "general classification," "chemistry," "immunology," "nonroutine dialysis," "hematology," "bacteriology & microbiology," and "urology";
(m) "Laboratory pathology," only subcategories "general classification," "cytology," "histology," and "biopsy";
(n) "Radiology - Diagnostic," only subcategories "general classification," "angiocardiography," "arthrography," "arteriography," and "chest X-ray";
(o) "Radiology - Therapeutic and/or chemotherapy administration," only subcategories "general classification," "chemotherapy administration - injected," "chemotherapy administration - oral," "radiation therapy," and "chemotherapy administration - IV";
(p) "Nuclear medicine," only subcategories "general classification," "diagnostic," "therapeutic," "diagnostic radiopharmaceuticals," and "therapeutic radiopharmaceuticals";
(q) "CT scan," only subcategories "general classification," "head scan," and "body scan";
(r) "Operating room services," only subcategories "general classification" and "minor surgery";
(s) "Anesthesia," only subcategories "general classification," "anesthesia incident to radiology," and "anesthesia incident to other diagnostic services";
(t) "Administration, processing and storage for blood and blood component," only subcategories "general classification" and "administration";
(u) "Other imaging services," only subcategories "general classification," "diagnostic mammography," "ultrasound," and "positron emission tomography";
(v) "Respiratory services," only subcategories "general classification," "inhalation services" and "hyperbaric oxygen therapy";
(w) "Physical therapy," only subcategories "general classification," "visit charge," "hourly charge," "group rate," and "evaluation or reevaluation";
(x) "Speech therapy - Language pathology," only subcategories "general classification," "visit charge," "hourly charge," "group rate," and "evaluation or reevaluation";
(y) "Emergency room," only subcategories "general, urgent care classification" and "urgent care";
(z) "Pulmonary function," only subcategory "general classification";
(aa) "Cardiology," only subcategories "general classification," "cardiac cath lab," "stress test," and "echocardiology";
(bb) "Ambulatory surgical care," only subcategory "general classification";
(cc) "Outpatient services," only subcategory "general classification";
(dd) "Magnetic resonance technology (MRT)," only subcategories "general classification," "MRI - Brain (including brainstem)," "MRI - Spinal cord (including spine)," "MRI-other," "MRA - Head and neck," "MRA - Lower extremities," and "MRA-other";
(ee) "Medical/surgical supplies - Extension," only subcategories "supplies incident to radiology," "supplies incident to other diagnostic services," and "surgical dressings";
(ff) "Pharmacy-extension," only subcategories "single source drug," "multiple source drug," "restrictive prescription," "erythropoietin (EPO) less than ten thousand units," "erythropoietin (EPO) ten thousand or more units," "drugs requiring detailed coding," and "self-administrable drugs";
(gg) "Cast room," only subcategory "general classification";
(hh) "Recovery room," only subcategory "general classification";
(ii) "Labor room/delivery," only subcategory "general
classification," "labor," "delivery," and "birthing center";
(jj) "EKG/ECG (Electrocardiogram)," only subcategories "general classification," "holter monitor," and "telemetry";
(kk) "EEG (Electroencephalogram)," only subcategory "general classification";
(ll) "Gastro-intestinal services," only subcategory "general classification";
(mm) "Treatment/observation room," only subcategories "general classification," "treatment room," and "observation room";
(nn) "Extra-corporeal shock wave therapy (formerly lithotripsy)," only subcategory "general classification";
(oo) "Inpatient renal dialysis," only subcategories "general classification," "inpatient hemodialysis," "inpatient peritoneal (non-CAPD)," "inpatient continuous ambulatory peritoneal dialysis (CAPD)," and "inpatient continuous cycling peritoneal dialysis (CCPD)";
(pp) "Acquisition of body components," only subcategories "general classification," "living donor," and "cadaver donor";
(qq) "Miscellaneous dialysis," only subcategory "ultra filtration";
(rr) "Other diagnostic services," only subcategories "general classification," "peripheral vascular lab," "electromyelogram," and "pregnancy test"; and
(ss) "Other therapeutic services," only subcategory "general classification."
(2) The agency pays for an inpatient hospital covered service in the following revenue code subcategories only when the hospital provider is approved by the agency to provide the specific service:
(a) "All-inclusive rate," only subcategory "all-inclusive room & board plus ancillary";
(b) "Room & board - Private (one bed)," only subcategory "psychiatric";
(c) "Room & board - Semi-private (two beds)," only subcategories "psychiatric," " withdrawal management," "rehabilitation," and "other";
(d) "Room & board - Semi-private three and four beds," only subcategories "psychiatric" and " withdrawal management";
(e) "Room & board - Deluxe private," only subcategory "psychiatric";
(f) "Room & board - Ward," only subcategories "general classification" and " withdrawal management";
(g) "Room & board - Other," only subcategories "general classification" and "other";
(h) "Intensive care unit," only subcategory "psychiatric";
(i) "Coronary care unit," only subcategory "heart transplant";
(j) "Operating room services," only subcategories "organ transplant-other than kidney" and "kidney transplant";
(k) "Occupational therapy," only subcategories "general classification," "visit charge," "hourly charge," "group rate" and "evaluation or reevaluation";
(l) "Clinic," only subcategory "chronic pain clinic";
(m) "Ambulance," only subcategory "neonatal ambulance services";
(n) "Behavioral health treatment/services," only subcategory "electroshock treatment"; and
(o) "Behavioral health treatment/services - Extension," only subcategory "rehabilitation."
(3) The agency pays revenue code category "occupational therapy," subcategories "general classification," "visit charge," "hourly charge," "group rate," and "evaluation or reevaluation" when:
(a) A client is in an acute PM&R facility;
(b) A client is age twenty or younger; or
(c) The diagnosis code is listed in the agency's published billing instructions.
(4) The agency does not pay for inpatient hospital services in the following revenue code categories and subcategories:
(a) "All-inclusive rate," subcategory "all-inclusive room and board";
(b) "Room & board - Private (one bed)" subcategories "hospice," " withdrawal management," "rehabilitation," and "other";
(c) "Room & board - Semi-private (two bed)," subcategory "hospice";
(d) "Room & board - Semi-private - (three and four beds)," subcategories "hospice," "rehabilitation," and "other";
(e) "Room & board - Deluxe private," subcategories "hospice," " withdrawal management," "rehabilitation," and "other";
(f) "Room & board - Ward," subcategories "medical/surgical/gyn," "OB," "pediatric," "psychiatric," "hospice," "oncology," "rehabilitation," and "other";
(g) "Room & board - Other," subcategories "sterile environment," and "self care";
(h) "Nursery," subcategory "other nursery";
(i) "Leave of absence";
(j) "Subacute care";
(k) "Intensive care unit," subcategory "other intensive care";
(l) "Coronary care unit," subcategory "other coronary care";
(m) "Special charges";
(n) "Incremental nursing charge";
(o) "All-inclusive ancillary";
(p) "Pharmacy," subcategories "take home drugs," "experimental drugs," and "other pharmacy";
(q) "IV therapy," subcategory "other IV therapy";
(r) "Medical/surgical supplies and devices," subcategories "take home supplies," "prosthetic/orthotics devices," "oxygen - take home," and "other supplies/devices";
(s) "Oncology," subcategory "other oncology";
(t) "Durable medical equipment (other than renal)";
(u) "Laboratory," subcategories "renal patient (home)," and "other laboratory";
(v) "Laboratory pathology," subcategory "other laboratory - pathological";
(w) "Radiology - Diagnostic," subcategory "other radiology - diagnostic";
(x) "Radiology - Therapeutic," subcategory "other radiology - therapeutic";
(y) "Nuclear medicine," subcategory "other nuclear medicine";
(z) "CT scan," subcategory "other CT scan";
(aa) "Operating room services," subcategory "other operating room services";
(bb) "Anesthesia," subcategories "acupuncture," and "other anesthesia";
(cc) "Blood and blood components";
(dd) "Administration, processing and storage for blood and blood components," subcategory "other processing and storage";
(ee) "Other imaging services," subcategories "screening mammography," and "other imaging services";
(ff) "Respiratory services," subcategory "other respiratory services";
(gg) "Physical therapy," subcategory "other physical therapy";
(hh) "Occupational therapy," subcategory "other occupational therapy";
(ii) "Speech therapy - Language pathology," subcategory "other speech-language pathology";
(jj) "Emergency room," subcategories "EMTALA emergency medical screening services," "ER beyond EMTALA screening," and "other emergency room";
(kk) "Pulmonary function," subcategory "other pulmonary function";
(ll) "Audiology";
(mm) "Cardiology," subcategory "other cardiology";
(nn) "Ambulatory surgical care," subcategory "other ambulatory surgical care";
(oo) "Outpatient services," subcategory "other outpatient service";
(pp) "Clinic," subcategories "general classification," "dental clinic," "psychiatric clinic," "OB-gyn clinic," "pediatric clinic," "urgent care clinic," "family practice clinic," and "other clinic";
(qq) "Free-standing clinic";
(rr) "Osteopathic services";
(ss) "Ambulance," subcategories "general classification," "supplies," "medical transport," "heart mobile," "oxygen," "air ambulance," "pharmacy," "telephone transmission EKG," and "other ambulance";
(tt) "Home health (HH) skilled nursing";
(uu) "Home health (HH) medical social services";
(vv) "Home health (HH) - Aide";
(ww) "Home health (HH) - Other visits";
(xx) "Home health (HH) - Units of service";
(yy) "Home health (HH) - Oxygen";
(zz) "Magnetic resonance technology (MRT)," subcategory "other MRT";
(aaa) "Medical" "medical/surgical supplies - extension," subcategory "FDA investigational devices";
(bbb) "Home IV therapy services";
(ccc) "Hospice services";
(ddd) "Respite care";
(eee) "Outpatient special residence charges";
(fff) "Trauma response";
(ggg) "Cast room," subcategory "other cast room";
(hhh) "Recovery room," subcategory "other recovery room";
(iii) "Labor room/delivery," subcategories "circumcision" and "other labor room/delivery";
(jjj) "EKG/ECG (Electrocardiogram)," subcategory "other EKG/ECG";
(kkk) "EEG (Electroencephalogram)," subcategory "other EEG";
(lll) "Gastro-intestinal services," subcategory "other gastro-intestinal";
(mmm) "Specialty room - Treatment/observation room," subcategory "other specialty rooms";
(nnn) "Preventive care services";
(ooo) "Telemedicine";
(ppp) "Extra-corporeal shock wave therapy (formerly lithotripsy)," subcategory "other ESWT";
(qqq) "Inpatient renal dialysis," subcategory "other inpatient dialysis";
(rrr) "Acquisition of body components," subcategories "unknown donor," "unsuccessful organ search - donor bank charges," and "other donor";
(sss) "Hemodialysis - Outpatient or home";
(ttt) "Peritoneal dialysis - Outpatient or home";
(uuu) "Continuous ambulatory peritoneal dialysis (CAPD) - Outpatient or home";
(vvv) "Continuous cycling peritoneal dialysis (CCPD) - Outpatient or home";
(www) "Miscellaneous dialysis," subcategories "general
classification," "home dialysis aid visit," and "other miscellaneous dialysis";
(xxx) "Behavioral health treatments/services," subcategories "general classification," "milieu therapy," "play therapy," "activity therapy," "intensive outpatient services - psychiatric," "intensive outpatient services - substance use disorder (SUD)," "community behavioral health program (day treatment)";
(yyy) "Behavioral health treatment/services" - (extension), subcategories "rehabilitation," "partial hospitalization - less intensive," "partial hospitalization - intensive," "individual therapy," "group therapy," "family therapy," "bio feedback," "testing," and "other behavioral health treatment/services";
(zzz) "Other diagnostic services," subcategories "general classification," "pap smear," "allergy test," and "other diagnostic service";
(aaaa) "Medical rehabilitation day program";
(bbbb) "Other therapeutic services," subcategories "recreational therapy," "cardiac rehabilitation," "drug rehabilitation," "alcohol rehabilitation," "complex medical equipment - routine," "complex medical equipment - ancillary," and "other therapeutic services";
(cccc) "Other therapeutic services - extension," subcategories "athletic training" and "kinesiotherapy";
(dddd) "Professional fees";
(eeee) "Patient convenience items"; and
(ffff) Revenue code categories and subcategories that are not identified in this section.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-15-128, § 182-550-1400, filed 7/21/21, effective 8/21/21; WSR 15-18-065, § 182-550-1400, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-1400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-018, § 388-550-1400, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. WSR 03-19-045, § 388-550-1400, filed 9/10/03, effective 10/11/03. Statutory Authority: RCW 74.08.090. WSR 01-02-075, § 388-550-1400, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-1400, filed 12/18/97, effective 1/18/98.]