Noncovered codes for outpatient hospital and ambulatory surgery settings - orthognathic surgery

Washington State Health Care Authority sent this bulletin at 11/04/2021 02:24 PM PDT

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Apple Health (Medicaid) Provider Alert

Billing for orthognathic surgeries

When billing for orthognathic surgeries, performed in conjunction with orthodontic treatment, the Health Care Authority (HCA) requires an expedited prior authorization (EPA) number, or if the EPA criteria is not met, prior authorization (PA) is required.

System limitations for outpatient hospital and ambulatory surgery center settings:

Due to system limitations, however, HCA is currently unable to cover the following codes in an outpatient hospital or ambulatory surgery center setting: CPT® 21151, 21154, 21155, 21159, 21160, 21194. HCA will cover these codes for inpatient hospital settings only, at this time.

Updated Orthodontic Services Billing Guide

HCA will update Orthodontic Services Billing Guide to reflect these changes by November 4, 2021. For more information on EPA codes and criteria, please see the Orthodontic Services Billing Guide.

About the Health Care Authority (HCA)

The Washington State Health Care Authority (HCA) is committed to whole-person care, integrating physical health and behavioral health services for better results and healthier residents.

HCA purchases health care for more than 2.5 million Washington residents through Apple Health (Medicaid), the Public Employees Benefits Board (PEBB) Program, the School Employees Benefits Board (SEBB) Program, and the COFA Islander Health Care Program. As the largest health care purchaser in the state, we lead the effort to transform health care, helping ensure Washington residents have access to better health and better care at a lower cost.

Please do not reply directly to this message. For more information, visit the HCA website, where you'll also find contact information.

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