Revised Physician-Related Services and Outpatient Hospital Billing Guide

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Apple Health (Medicaid) Provider Alert

The Health Care Authority (HCA) revised the Physician-Related Services/Health Care Professional Services Billing Guide.

What has changed?

The agency:

  • Corrected the age restriction for sacroiliac joint fusion.
  • Clarified that prior authorization is not required for CPT codes 92071, 92072, V2630, V2631, and V2632 in the vision coverage table.
  • Added procedure code J9210 to the list of drugs administered to managed care clients but reimbursed through fee for service.
  • Added a new section on breast and ovarian genetic testing with the addition of a new expedited prior authorization (EPA) code.

For specific details, see the What has changed table in the revised guide.

The agency also updated the Outpatient Hospital Billing Guide to include a new section for breast and ovarian genetic testing. The updated guides are available on the HCA provider billing guides webpage, dated November 1, 2019.