Drug pricing update and additional EPA code for genomic oncology testing added to Physician-Related/Professional Services Billing Guide

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Apple Health (Medicaid) Provider Alert

The Health Care Authority (HCA) has published an updated Physician-Related/Professional Services Billing Guide, effective November 12, 2017.

  • The updated billing guide reflects changes to WAC 182-531-0050, 182-531-0950, and 182-531-1850 to comply with CMS-2345-FC, Covered Outpatient Drug Rule.  This changed how HCA prices drugs from average wholesale price (AWP) to point-of-sale (POS) actual acquisition cost (AAC).
  • The updated guide also has a new Expedited Prior Authorization (EPA) number 870001420 for oncology (breast) genomic testing. Oncology genomic (breast) testing is conducted by two companies (Endopredict and Oncotype). The tests use the same CPT® code but different EPA numbers must be used depending upon which company conducted the test.