MedicaidCoverageHigh impact
Aligning skin substitutes policy between professional and outpatient settings, Eff 1/1/2027
Washington Apple Health·WA · Wound Care, Plastic Surgery, Dermatology +1 more·Medical Policy
Effective date
Jan 1, 2027
We identified it
Oct 3, 2026
Summary
Effective January 1, 2027, Washington State's Apple Health (Medicaid) is aligning skin substitutes coverage between professional and outpatient hospital settings. Only six specific skin substitute codes (Q4101, Q4102, Q4128, Q4132, Q4133, Q4186) will remain covered; all other skin substitutes will be discontinued in outpatient hospital settings, requiring billing teams to verify code eligibility before claim submission.
Action Required
By December 31, 2026: Billing team must update billing system to restrict outpatient hospital claims to ONLY the six covered skin substitute codes (Q4101, Q4102, Q4128, Q4132, Q4133, Q4186) for Apple Health (Medicaid) patients in Washington. Implement system edits to deny or flag any other skin substitute codes submitted for outpatient hospital settings effective 1/1/2027. Update claim scrubber rules and provider documentation templates to reflect covered code list. Train billing staff and providers on the change to prevent denials. Any skin substitute codes not listed will be denied for dates of service on or after January 1, 2027 in outpatient hospital settings (including critical access and rural emergency hospitals). Reference the updated Physician-Related Services/Health Care Professional Services Billing Guide from HCA.