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DATE: December 2, 2010
TO: Norene Lind, Regulatory Affairs Manager
State Office of Administrative Hearings and Rules
FROM: Billie Newsom, Administrator Health Care Services
Workers’ Compensation Agency, Department of Energy Labor and Economic Growth
SUBJECT: Request for correction of the Workers’ Compensation Health Care Services R 418.10107 Rule 107, (a), R 418.10109(h), (t), (u),
R 418.101023 (2), and Rule 418.10107 Rule 107, pursuant to Administrative Procedures
Act, Section 56(1), MCL 24.256 (1).
2010-030 LG Health Care Services Effective December 8, 2010
The Workers’ Compensation Agency - Health Care Services division, as a promulgating agency, is writing to request that the State Office of Administrative Hearings and Rules exercise its discretion to fix obvious errors.
Also, in subsection (a) "Physicians' Current Procedural Terminology (CPT®) 2010," professional edition, copyright October
20082009, published by the American Medical association, PO Box 930884, Atlanta GA, 31193-0884, order #EP888810, 1-800-621-8335. The publication may be purchased at a cost of $107.95, plus shipping and handling as of the time of adoption of these rules. Permission to use this publication is on file in the workers' compensation agency. The “2008” should be deleted.The second obvious error appears in R418.10109 subsections (h) “the provision of” should be deleted,
(t) the extra spaces should be deleted between health and care, and (u) the “one” should be deleted.
(h) "Nursing home" means a nursing care facility, including a county medical care facility, created pursuant to
the provision of1885 PA 152, MCL 36.1. The “the provision of “ should be deleted.(t) "Specialist" means any of the following entities that are board-certified, board-eligible, or otherwise considered an expert in a particular field of health care by virtue of education, training, and experience generally accepted in that particular field.
(i) A doctor of chiropractic.
(ii) A doctor of dental surgery.
(iii) A doctor of medicine.
(iv) A doctor of optometry.
(v) A doctor of osteopathic medicine and surgery.
(vi) A doctor of podiatric medicine and surgery.
:
(u), "Subrogation" means substituting
one1 creditor for another. An example of subrogation in workers' compensation is when a case is determined to be workers' compensation and the health benefits plan has already paid for the service and is requesting the workers' compensation carrier or the provider to refund the money that the plan paid on behalf of the worker. The “one” should be deleted.The third obvious error is in Rule 418.101023
(3)(2) When 2 or more surgical procedures are performed in the same operative session, the facility shall be reimbursed at 100% of the maximum allowable payment or the facility's usual and customary charge, whichever is less, for the procedure classified in the highest payment group. The “(3)” should be deleted.The forth obvious error is in Rule 418.10107
Below you will find the corrected rules:
R 418.10107 Source documents; adoption by reference.
Rule 107. The following documents are adopted by reference in these rules and are available for inspection and distribution from the Workers' Compensation Agency, Health Care Services Division,
P.O. Box 30016, Lansing, Michigan 48909, at the cost listed in subdivisions (a) to (g) of this rule, or directly from the organizations listed:
(a) "Physicians' Current Procedural Terminology (CPT®) 2010," professional edition, copyright October 2009, published by the American Medical association, PO Box 930884, Atlanta GA, 31193- 0884, order #EP888810, 1-800-621-8335. The publication may be purchased at a cost of $107.95, plus shipping and handling as of the time of adoption of these rules. Permission to use this publication is on file in the workers' compensation agency.
(b) "Medicare's National Level II Codes, HCPCS, 2010:” copyright December 2009, published by the American Medical Association, P.O. Box 930884 Atlanta GA 31193-0884, order #OP231510, customer service 1-800-621-8335. The publication may be purchased at a cost of $94.95, plus $11.95 for shipping and handling as of the time of adoption of these rules.
(c) "Medicare RBRVS 2009: The Physicians' Guide," published by The American Medical Association, P.O. Box 930876, Atlanta GA 31193-0876, order #OP059609 1-800-621-8335. The publication may be purchased at a cost of $91.95, plus $11.95 shipping and handling as of the time of adoption of these rules.
(d) "Medicare RBRVS 2010: The Physicians' Guide," published by The American Medical Association, P.O. Box 930884, Atlanta GA 31193-0884, order #OP059610 1-800-621-8335. The publication may be purchased at a cost of $91.95, plus $11.95 shipping and handling as of the time of adoption of these rules.
(e) "International Classification of Diseases, ICD 9 CM 2010 Volumes 1 & 2," copyright September 2009, American Medical Association, P.O. Box 930884, Atlanta GA 31193-0884, order #OP065110,
1-800-621-8335. The publication may be purchased at a cost of $92.95, plus $11.95 shipping and handling as of the time of adoption of these rules.
(f) "2010 Red Book," published by PDR Distribution LLC PO Box 2244, 82 Winter Sport Lane, Williston, VT 05495, 1-800-678-5689. The publication may be purchased at a cost of $76.95, plus
$12.95 for shipping and handling as of the time of adoption of these rules.
(g) "Official UB-04 Data Specifications Manual 2010 (v. 3.00), July 1, 2009" developed in cooperation with the American Hospital Association’s National Uniform Billing committee, published by American Hospital Association, National Uniform Billing Committee - UB-04, P.O. Box 92247, Chicago, IL 60675-2247, 1-312-422-3390. As of the time of adoption of these rules, the cost of the publication is
$150.00.
R 418.10109 Definitions; M to U. Rule 109. As used in these rules:
(a) "Maximum allowable payment" means the maximum fee for a procedure that is established by these rules, a reasonable amount for a "by report" procedure, or a provider's usual and customary charge, whichever is less.
(b) "Medical only case" means a case that does not involve wage loss compensation.
(c) "Medical rehabilitation" means, to the extent possible, the interruption, control, correction, or amelioration of a medical or a physical problem that causes incapacity through the use of appropriate treatment disciplines and modalities that are designed to achieve the highest possible level of post-injury function and a return to gainful employment.
(d) "Medically accepted standards" means a measure which is set by a competent authority as the rule for evaluating quantity or quality of health care or health care services ensuring that the health care is suitable for a particular person, condition, occasion, or place.
(e) "Morbidity" means the extent of illness, injury, or disability.
(f) "Mortality" means the likelihood of death.
(g) "New patient" means a patient who is new to the provider for a particular covered injury or illness and who needs to have medical and administrative records established.
(h) "Nursing home" means a nursing care facility, including a county medical care facility, created pursuant to 1885 PA 152, MCL 36.1.
(i) "Orthotic equipment" means an orthopedic apparatus that is designed to support, align, prevent, or correct deformities of, or improve the function of, a movable body part.
(j) "Pharmacy" means the place where the science, art, and practice of preparing, preserving, compounding, dispensing, and giving appropriate instruction in the use of drugs is practiced.
(k) "Practitioner" means an individual who is licensed, registered, or certified as used in the Michigan public health code, 1978 PA 368, MCL 333.1101.
(l) "Primary procedure" means the therapeutic procedure that is most closely related to the principal diagnosis and has the highest assigned relative value unit (RVU).
(m) ) "Properly submitted bill" means a request by a provider for payment of health care services which is submitted to a carrier on the appropriate completed claim form with attachments as required by these rules.
(n) "Prosthesis" means an artificial substitute for a missing body part. A prosthesis is constructed by a "prosthetist", a person who is skilled in the construction and application of a prosthesis.
(o) "Provider" means a facility, health care organization, or a practitioner.
(p) "Reasonable amount" means a payment based upon the amount generally paid in the state for a particular procedure code using data available from the provider, the carrier, or the workers' compensation agency, health care services division.
(q) "Restorative" means that the patient's function will demonstrate measurable improvement in a reasonable and generally predictable period of time and includes appropriate periodic care to maintain the level of function.
(r) "Secondary procedure" means a surgical procedure which is performed to ameliorate conditions that are found to exist during the performance of a primary surgery and which is considered an independent procedure that may not be performed as a part of the primary surgery or for the existing condition.
(s) “Separate procedure” means procedures or services listed in the CPT codebook that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of a term “separate procedure.”
(t) "Specialist" means any of the following entities that are board-certified, board-eligible, or otherwise considered an expert in a particular field of health care by virtue of education, training, and experience generally accepted in that particular field:
(i) A doctor of chiropractic.
(ii) A doctor of dental surgery.
(iii) A doctor of medicine.
(iv) A doctor of optometry.
(v) A doctor of osteopathic medicine and surgery.
(vi) A doctor of podiatric medicine and surgery.
(u) "Subrogation" means substituting 1 creditor for another. An example of subrogation in workers' compensation is when a case is determined to be workers' compensation and the health benefits plan has already paid for the service and is requesting the workers' compensation carrier or the provider to refund the money that the plan paid on behalf of the worker.
(v) "Technical surgical assist" means that additional payment for an assistant surgeon, referenced in R 418.10416, is allowed for certain designated surgical procedures. The Health Care Services Manual,published annually by the workers' compensation agency, denotes a surgical procedure allowing payment for the technical surgical assist with the letter "T."
(w) "Treatment plan" means a plan of care for restorative physical treatment services that indicates the diagnosis and anticipated goals.
(x) "Usual and customary charge" means a particular provider's average charge for a procedure to all payment sources, and includes itemized charges which were previously billed separately and which are included in the package for that procedure as defined by these rules. A usual and customary charge for a procedure shall be calculated based on data beginning January 1, 2000.
R 418.101023 Reimbursement for ASC or FSOF.
Rule 1023. (1) Reimbursement for surgical procedures performed in a ASC or FSOF shall be determined by using the CMS ASC rate that is published in the Federal Register. The formula for determining the maximum allowable paid (MAP) for a surgical procedure in an ASC or FSOF is determined by multiplying the (Medicare ASC rate) X (1.30). The MAP shall be published in the health care services fee schedule.
(2) When 2 or more surgical procedures are performed in the same operative session, the facility shall be reimbursed at 100% of the maximum allowable payment or the facility's usual and customary charge, whichever is less, for the procedure classified in the highest payment group. Any other surgical procedures performed during the same session shall be reimbursed at 50% of the maximum allowable payment or 50% of the facility's usual and customary charge, whichever is less. A facility shall not un- bundle surgical procedure codes when billing the services.
(3) When an eligible procedure is performed bilaterally, each procedure shall be listed on a separate line of the claim form and shall be identified with LT for left and RT for right. At no time shall modifier 50 be used by the facility to describe bilateral procedures.
(4) Implants are included in the maximum allowable paid unless the CMS list it as a pass through item. Pass through items will be listed in the health care service manual. If an item is implanted during the surgical procedure and the ASC or FSOF bills the implant and includes the copy of the invoice, then the implant shall be reimbursed at the cost of the implant plus a percent markup as follows:
(a) Cost of implant: $1.00 to $500.00 shall receive cost plus 50%.
(b) Cost of implant: $500.01 to $1000.00 shall receive cost plus 30%.
(c) Cost of implant: $1000.01 and higher shall receive cost plus 25%.
(5) Laboratory services shall be reimbursed by the maximum allowable payment as determined in R 418.101503.
(6) When a radiology procedure is performed intra-operatively only the technical component shall be billed by the facility and reimbursed by the carrier. The professional component shall be included with the surgical procedure. Pre-operative and post-operative radiology services may be globally billed.
(7) When the freestanding surgical facility provides durable medical equipment, the items shall be reimbursed in accord with R 418.101003b.
If you have additional questions please contact me at 517-.322-5896.
