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Chapter 182-550 WAC

Last Update: 7/24/14

HOSPITAL SERVICES

WAC Sections

Applicability.
Hospital services definitions.
Hospital careGeneral.
Restrictions on hospital coverage.
Revenue code categories and subcategories.
Revenue code categories and subcategoriesCPT and HCPCS reporting requirements for outpatient hospitals.
Covered and noncovered revenue codes categories and subcategories for inpatient hospital services.
Covered and noncovered revenue code categories and subcategories for outpatient hospital services.
Specific items/services not covered.
Adverse events, hospital-acquired conditions, and present on admission indicators.
Authorization and utilization review (UR) of inpatient and outpatient hospital services.
Hospital specialty services not requiring prior authorization.
Transplant coverage.
RequirementsTransplant hospitals.
Transplant requirementsCOE.
Hospital and medical criteria requirements for bariatric surgery.
Inpatient chronic pain management services.
Hospice servicesInpatient payments.
Inpatient hospice services.
Acute physical medicine and rehabilitation (acute PM&R) programGeneral.
Client eligibility requirements for acute PM&R services.
Requirements for becoming an acute PM&R provider.
Quality of careDepartment-approved acute PM&R hospital.
How a client qualifies for acute PM&R services.
The department's prior authorization requirements for acute PM&R services.
The long-term acute care (LTAC) programGeneral.
Client eligibility requirements for LTAC services.
Requirements for becoming an LTAC hospital.
LTAC hospitalsQuality of care.
Department prior authorization requirements for Level 1 and Level 2 LTAC services.
Identification of and payment methodology for services and equipment included in the LTAC fixed per diem rate.
Services and equipment covered by the department but not included in the LTAC fixed per diem rate.
Critical access hospitals (CAHs).
Inpatient psychiatric services.
Base community psychiatric hospitalization payment method for medicaid and CHIP clients and nonmedicaid and non-CHIP clients.
Hospital discharge planning services.
Payment limitsInpatient hospital services.
Payment method.
Payment method for acute PM&R services and administrative day services.
Case-mix index.
Payment methodBariatric surgeryPer case rate.
Diagnosis-related group (DRG) paymentHospital transfers.
DRG high outliers.
Rebasing.
Budget neutrality adjustment and measurement.
Payment methodBordering city hospitals and critical border hospitals.
Payment methodOut-of-state hospitals.
Payment methodNew hospitals.
Change in hospital ownership.
Hospitals and units exempt from the DRG payment method.
ServicesExempt from DRG payment.
Payment methodRatio of costs-to-charges (RCC).
Administrative day rate and swing bed day rate.
"Full cost" public hospital certified public expenditure (CPE) payment program.
CPE payment program"Hold harmless" provision.
Authorization requirements and utilization review for hospitals eligible for CPE payments.
PaymentNon-SCA participating hospitals.
Hospital payment methodsState-administered programs.
Disproportionate share hospital (DSH) paymentsGeneral provisions.
Eligibility for DSH programsNew hospital providers.
DSH eligibilityChange in hospital ownership.
Payment methodLow income disproportionate share hospital (LIDSH).
Payment methodInstitution for mental diseases disproportionate share hospital (IMDDSH) and institution for mental diseases (IMD) state grants.
Payment methodMedical care services disproportionate share hospital (MCSDSH).
Payment methodSmall rural disproportionate share hospital (SRDSH).
Payment methodSmall rural indigent assistance disproportionate share hospital (SRIADSH).
Payment methodNonrural indigent assistance disproportionate share hospital (NRIADSH).
Payment methodChildren's health program disproportionate share hospital (CHPDSH).
Payment methodSole community disproportionate share hospital (SCDSH).
Payment methodPublic hospital disproportionate share hospital (PHDSH).
CPE medicaid cost report and settlements.
Upper payment limit (UPL) payments for inpatient hospital services.
Supplemental distributions to approved trauma service centers.
PaymentHospital-based RHCs.
Public notice for changes in medicaid payment rates for hospital services.
Dispute resolution process for hospital rate reimbursement.
Hospital reports and audits.
Outpatient and emergency hospital services.
Outpatient hospital servicesConditions of payment and payment methods.
Outpatient hospital physical therapy.
Outpatient hospital occupational therapy.
Outpatient hospital speech therapy services.
PregnancyEnhanced outpatient benefits.
Outpatient nutritional counseling.
Outpatient hospital diabetes education.
Outpatient hospital weight loss program.
Blood and blood components.
Hospital-based physician services.
Hospital services provided out-of-state.
Outpatient prospective payment system (OPPS)General.
OPPSBilling requirements and payment method.
OPPSPayment limitations.
OPPS EAPG relative weights.
OPPS budget target adjustor.
OPPS rate.
OPPS payment enhancements.
OPPS payment calculation.
DISPOSITION OF SECTIONS FORMERLY CODIFIED IN THIS CHAPTER
182-550-2511
Acute PM&R definitions. [WSR 11-14-075, recodified as § 182-550-2511, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 07-12-039, § 388-550-2511, filed 5/30/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.520 and 42 C.F.R. 482.56. WSR 03-06-047, § 388-550-2511, filed 2/28/03, effective 3/31/03. Statutory Authority: RCW 74.08.090 and 74.09.520. WSR 99-17-111, § 388-550-2511, filed 8/18/99, effective 9/18/99.] Repealed by WSR 14-12-047, filed 5/29/14, effective 7/1/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW.
182-550-2570
LTAC program definitions. [WSR 11-14-075, recodified as § 182-550-2570, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 08-21-039, § 388-550-2570, filed 10/8/08, effective 11/8/08; WSR 07-11-129, § 388-550-2570, filed 5/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090. WSR 02-14-162, § 388-550-2570, filed 7/3/02, effective 8/3/02.] Repealed by WSR 14-12-047, filed 5/29/14, effective 7/1/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW.
182-550-2800
Payment methods and limitsInpatient hospital services for medicaid and SCHIP clients. [WSR 11-14-075, recodified as § 182-550-2800, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-063, § 388-550-2800, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-018, § 388-550-2800, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.500, and 2005 c 518, § 204, Part II. WSR 07-06-043, § 388-550-2800, filed 3/1/07, effective 4/1/07. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-12-022, § 388-550-2800, filed 5/20/05, effective 6/20/05. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 04-19-113, § 388-550-2800, filed 9/21/04, effective 10/22/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. WSR 02-21-019, § 388-550-2800, filed 10/8/02, effective 11/8/02. Statutory Authority: RCW 74.08.090 and 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, .11303, and .2652. WSR 01-16-142, § 388-550-2800, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW 74.09.090, 42 U.S.C. 1395x(v) and 1396r-4, 42 C.F.R. 447.271, 11303 and 2652. WSR 99-14-027, § 388-550-2800, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 42 U.S.C. 1395 x(v), 42 C.F.R. 447.271, 447.11303, and 447.2652. WSR 99-06-046, § 388-550-2800, filed 2/26/99, effective 3/29/99. 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, § 388-550-2800, filed 12/18/97, effective 1/18/98.] Repealed by WSR 14-12-047, filed 5/29/14, effective 7/1/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW.
182-550-3010
Payment methodPer diem payment. [WSR 11-14-075, recodified as § 182-550-3010, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-063, § 388-550-3010, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-3010, filed 6/28/07, effective 8/1/07.] Repealed by WSR 14-12-047, filed 5/29/14, effective 7/1/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW.
182-550-3020
Payment methodBariatric surgeryPer case payment. [WSR 11-14-075, recodified as § 182-550-3020, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-063, § 388-550-3020, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-3020, filed 6/28/07, effective 8/1/07.] Repealed by WSR 14-12-047, filed 5/29/14, effective 7/1/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW.
182-550-3100
Calculating DRG relative weights. [WSR 11-14-075, recodified as § 182-550-3100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-3100, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.04.050. WSR 04-13-048, § 388-550-3100, filed 6/10/04, effective 7/11/04. Statutory Authority: RCW 74.08.090, 42 U.S.C. 1395 x(v), 42 C.F.R. 447.271, 447.11303, and 447.2652. WSR 99-06-046, § 388-550-3100, filed 2/26/99, effective 3/29/99. 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, § 388-550-3100, filed 12/18/97, effective 1/18/98.] Repealed by WSR 14-12-047, filed 5/29/14, effective 7/1/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW.
182-550-3150
Base period costs and claims data. [WSR 11-14-075, recodified as § 182-550-3150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-3150, filed 6/28/07, effective 8/1/07. 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, § 388-550-3150, filed 12/18/97, effective 1/18/98.] Repealed by WSR 14-12-047, filed 5/29/14, effective 7/1/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW.
182-550-3200
Medicaid cost proxies. [WSR 11-14-075, recodified as § 182-550-3200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 07-14-055, § 388-550-3200, filed 6/28/07, effective 8/1/07. 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, § 388-550-3200, filed 12/18/97, effective 1/18/98.] Repealed by WSR 14-12-047, filed 5/29/14, effective 7/1/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW.
182-550-3250
Indirect medical education costsConversion factors, per diem rates, and per case rates. [WSR 11-14-075, recodified as § 182-550-3250, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-3250, filed 6/28/07, effective 8/1/07. 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, § 388-550-3250, filed 12/18/97, effective 1/18/98.] Repealed by WSR 14-12-047, filed 5/29/14, effective 7/1/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW.
182-550-3300
Hospital peer groups and cost caps. [WSR 11-14-075, recodified as § 182-550-3300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 07-14-055, § 388-550-3300, filed 6/28/07, effective 8/1/07; WSR 06-08-046, § 388-550-3300, filed 3/30/06, effective 4/30/06. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 05-12-132, § 388-550-3300, filed 6/1/05, effective 7/1/05. Statutory Authority: RCW 74.08.090 and 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, .11303, and .2652. WSR 01-16-142, § 388-550-3300, filed 7/31/01, effective 8/31/01. 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, § 388-550-3300, filed 12/18/97, effective 1/18/98.] Repealed by WSR 14-12-047, filed 5/29/14, effective 7/1/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW.
182-550-3350
Outlier costs. [WSR 11-14-075, recodified as § 182-550-3350, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 07-14-055, § 388-550-3350, filed 6/28/07, effective 8/1/07. 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, § 388-550-3350, filed 12/18/97, effective 1/18/98.] Repealed by WSR 14-12-047, filed 5/29/14, effective 7/1/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW.
182-550-3450
Payment method for calculating medicaid DRG conversion factor rates. [WSR 11-14-075, recodified as § 182-550-3450, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-3450, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.09.090, 42 U.S.C. 1395x(v) and 1396r-4, 42 C.F.R. 447.271, 11303 and 2652. WSR 99-14-027, § 388-550-3450, filed 6/28/99, effective 7/1/99. 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, § 388-550-3450, filed 12/18/97, effective 1/18/98.] Repealed by WSR 14-12-047, filed 5/29/14, effective 7/1/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW.
182-550-3460
Payment methodPer diem rate. [WSR 11-14-075, recodified as § 182-550-3460, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-063, § 388-550-3460, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-3460, filed 6/28/07, effective 8/1/07.] Repealed by WSR 14-12-047, filed 5/29/14, effective 7/1/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW.
182-550-3500
Hospital annual inflation adjustment determinations. [WSR 11-14-075, recodified as § 182-550-3500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 07-14-055, § 388-550-3500, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.09.090, 42 U.S.C. 1395x(v) and 1396r-4, 42 C.F.R. 447.271, 11303 and 2652. WSR 99-14-027, § 388-550-3500, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 42 U.S.C. 1395 x(v), 42 C.F.R. 447.271, 447.11303, and 447.2652. WSR 99-06-046, § 388-550-3500, filed 2/26/99, effective 3/29/99. 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, § 388-550-3500, filed 12/18/97, effective 1/18/98.] Repealed by WSR 14-12-047, filed 5/29/14, effective 7/1/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW.
182-550-4600
Hospital selective contracting program. [WSR 11-14-075, recodified as § 182-550-4600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-12-040, § 388-550-4600, filed 5/30/07, effective 7/1/07; WSR 06-08-046, § 388-550-4600, filed 3/30/06, effective 4/30/06. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 05-12-132, § 388-550-4600, filed 6/1/05, effective 7/1/05. 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, § 388-550-4600, filed 12/18/97, effective 1/18/98.] Repealed by WSR 14-12-047, filed 5/29/14, effective 7/1/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW.
182-550-5125
Payment methodPsychiatric indigent inpatient disproportionate share hospital (PIIDSH). [WSR 11-14-075, recodified as § 182-550-5125, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-090, § 388-550-5125, filed 6/29/07, effective 8/1/07; WSR 06-08-046, § 388-550-5125, filed 3/30/06, effective 4/30/06.] Repealed by WSR 14-16-019, filed 7/24/14, effective 8/24/14. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155.
182-550-6350
Outpatient sleep apnea/sleep study programs. [WSR 11-14-075, recodified as § 182-550-6350, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-13-100, § 388-550-6350, filed 6/20/07, effective 8/1/07. 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, § 388-550-6350, filed 12/18/97, effective 1/18/98.] Repealed by WSR 13-07-029, filed 3/13/13, effective 4/13/13. Statutory Authority: RCW 41.05.021.
182-550-7050
OPPSDefinitions. [WSR 11-14-075, recodified as § 182-550-7050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.09.500, and 74.09.530. WSR 10-08-023, § 388-550-7050, filed 3/30/10, effective 4/30/10. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-062, § 388-550-7050, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-13-100, § 388-550-7050, filed 6/20/07, effective 8/1/07; WSR 04-20-061, § 388-550-7050, filed 10/1/04, effective 11/1/04.] Repealed by WSR 14-12-047, filed 5/29/14, effective 7/1/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW.
182-550-7100
OPPSExempt hospitals. [WSR 11-14-075, recodified as § 182-550-7100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-062, § 388-550-7100, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-13-100, § 388-550-7100, filed 6/20/07, effective 8/1/07; WSR 04-20-061, § 388-550-7100, filed 10/1/04, effective 11/1/04.] Repealed by WSR 14-14-049, filed 6/25/14, effective 7/26/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW.