HCA Outpatient Billing Guide Includes Updates for Naloxone Billing, “PO” Modifier Usage

February 23, 2022

The Washington State Health Care Authority (HCA) updated its Outpatient Hospital Billing Guide yesterday. The guide provides updated information on two key topics:

Billing for take-home opioid reversal medication (Naloxone) distributed in emergency departments (page 3 and page 43). A new law, Senate Bill 5195, enacted during the 2021 legislative session, requires hospitals and certain behavioral health providers to provide opioid reversal medication to certain patients. Retroactively to January 1, 2021, hospitals can bill the Medicaid enrollee’s MCO with codes J2310, J3490, G1028, along with their appropriate NDC codes for take-home opioid reversal medication dispensed in the emergency department. This can be charged as a separate service line and will be paid in addition to the payment for the emergency service. The payment amounts for the codes are according to the OPPS Fee Schedule. We are awaiting information from HCA on how hospitals can bill HCA for opioid reversal medication provided to uninsured emergency department patients. On a related note, WSHA supports House Bill 1761 which clarifies the law in order to ensure nurses can dispense the medication in the emergency department. Please see our Bulletin for more information.

Use of “PO” modifier for off-campus hospital-based department sites (page 3 and page 42). HCA has revised its instructions for billing this modifier used to identify off-campus hospital-based services to conform with CMS definitions. The updated guide modifies the definition of modifier PO and adds a reference to 42 CFR § 419.48 for a description of excepted items and services. We recommend hospital billing staff review the updated guide to determine if any changes to how the modifier is used and billed are needed. (Andrew Busz, Andrewb@wsha.org).


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