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DEPARTMENT OF ENERGY, LABOR, AND ECONOMIC GROWTH WORKERS’ COMPENSATION AGENCY
WORKERS’ COMPENSATION HEALTH CARE SERVICES
Filed with the Secretary of State on December 1, 2010
These rules become effective 7 days after filing with the Secretary of State
(By authority conferred on the workers’ compensation agency by sections 205 and 315 of 1969 PA 317, section 33 of 1969 PA 306, Executive Reorganization Order Nos. 1982-2, 1986-3, 1990-1, 1996-2, and
2003-1, MCL 418.205, 418.315, 24.233, 18.24, 418.1, 418.2, 445.2001, and 445.2011)
R 418.10107, R 418.10108, R 418.10109, R 418.10205, R 418.10212, R 418.10214, R 418.10905, R 418.10923b, R 418.101002a, R 418.101003a, R 418.101023, R 418.101206, and R 418.101401 of the
Michigan Administrative Code are amended and R 418.101002b is rescinded as follows:
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
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.
(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 418.10108 Definitions; A to I. Rule 108. As used in these rules:
(a) "Act" means 1969 PA 317, MCL 418.101 et seq.
(b) "Adjust" means that a carrier or a carrier's agent reduces a health care provider's request for payment to the maximum fee allowed by these rules, to a provider's usual and customary charge, or, when the maximum fee is by report, to a reasonable amount. “Adjust” also means when a carrier re- codes a procedure, or reduces payment as a result of professional review.
(c) "Agency" means the workers' compensation agency in the department of energy, labor, and economic growth.
(d) “Ambulatory surgical center” (ASC) means an entity that operates exclusively for providing surgical services to patients not requiring hospitalization and has an agreement with the centers for Medicare and Medicaid services (CMS) to participate in Medicare.
(e) "Appropriate care" means health care that is suitable for a particular person, condition, occasion, or place.
(f) "BR" or "by report" means that the procedure is not assigned a relative value unit, (RVU) or a maximum fee and requires a written description.
(g) "Carrier" means an organization which transacts the business of workers' compensation insurance in Michigan and which may be any of the following:
(i) A private insurer.
(ii) A self-insurer.
(iii) One of the funds of chapter 5 of the act.
(h) "Case" means a covered injury or illness which occurs on a specific date and which is identified by the worker's name and date of injury or illness.
(i) "Case record" means the complete health care record which is maintained by a carrier and which pertains to a covered injury or illness that occurs on a specific date.
(j) "Complete procedure" means a procedure that contains a series of steps that are not to be billed separately.
(k) "Covered injury or illness" means an injury or illness for which treatment is mandated by section 315 of the act.
(l) "Current procedural terminology", (CPT®)" means a listing of descriptive terms and identifying codes and provides a uniform nationally accepted nomenclature for reporting medical services and procedures. "Current procedural terminology" provides instructions for coding and claims processing.
(m) "Dispute" means a disagreement between a carrier or a carrier's agent and a health care provider on the application of these rules.
(n) "Durable medical equipment" means specialized equipment which is designed to stand repeated use, which is used to serve a medical purpose, and which is appropriate for home use.
(o) "Emergency condition" means that a delay in treating a patient would lead to a significant increase in the threat to the patient's life or to a body part.
(p) "Established patient" means a patient whose medical and administrative records for a particular covered injury or illness are available to the provider.
(q) "Expendable medical supply" means a disposable article that is needed in quantity on a daily or monthly basis.
(r) "Facility" means an entity licensed by the state in accord with 1978 PA 368, MCL 333.1101 et seq. The office of an individual practitioner is not considered a facility.
(s) "Focused review" means the evaluation of a specific health care service or provider to establish patterns of use and dollar expenditures.
(t) "Follow-up days" means the days of care following a surgical procedure that are included in the procedure's maximum allowable payment, but does not include care for complications. If the surgical procedure lists "xxx" for the follow-up days, then the global concept does not apply. If "yyy" is listed for follow-up days, then the carrier shall set the global period. If "zzz" is used, then the procedure code is part of another service and falls within the global period of the other service.
(u) “Free standing outpatient facility” (FSOF) means a facility, other than the office of a physician, dentist, podiatrist, or other private practice, offering a surgical procedure and related care that in the opinion of the attending physician can be safely performed without requiring overnight inpatient hospital care.
(v) "Health care organization" means a group of practitioners or individuals joined together to provide health care services and includes any of the following:
(i) Health maintenance organization.
(ii) Industrial or other clinic.
(iii) Occupational health care center.
(iv) Home health agency.
(v) Visiting nurse association.
(vi) Laboratory.
(vii) Medical supply company.
(viii) Community mental health board.
(w) "Health care review" means the review of a health care case or bill, or both, by a carrier, and includes technical health care review and professional health care review.
(x) "Incidental surgery" means a surgery which is performed through the same incision, on the same day, by the same doctor of dental surgery, doctor of medicine, doctor of osteopathy, or doctor of podiatry and which is not related to diagnosis.
(y) "Independent medical examination" means an examination and evaluation which is requested by a carrier or an employee and which is conducted by a different practitioner than the practitioner who provides care.
(z) "Industrial medicine clinic" also referred to as an “occupational health clinic" means an organization that primarily treats injured workers. The industrial medicine clinic or occupational clinic may be a health care organization as defined by these rules or may be a clinic owned and operated by a hospital for the purposes of treating injured workers.
(aa) "Insured employer" means an employer who purchases workers' compensation insurance from an insurance company that is licensed to write insurance in the state of Michigan.
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
the provision of1885 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
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.(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 418.10205 Consultation services.
Rule 205. (1) An attending physician, carrier, third-party administrator, or the injured worker may request a consultation. Codes 99241-99245 and 99251-99255 shall not be used for consultation examinations. Providers shall use the evaluation code that most accurately reflects the service rendered. (2)If a specialist performs diagnostic procedures or testing in addition to the evaluation, then the specialist shall bill the appropriate procedure code from "Physicians' Current Procedural Terminology (CPT®). The carrier shall reimburse the testing procedures in accordance with these rules.
R418.10212 Physical and occupational therapy; physical medicine services; physical treatment.
Rule 212. (1) For the purposes of workers’ compensation, physical medicine services, procedure codes 97010-97799, shall be referred to as "physical treatment" when the services are provided by a practitioner other than a physical therapist or an occupational therapist. Physical therapy means physical treatment provided by a licensed physical therapist. Occupational therapy means physical treatment provided by an occupational therapist.
(2) Physical medicine services shall be restorative. If documentation does not support the restorative nature of the treatment, then the service shall not be reimbursed.
(3) Any of the following may provide physical treatment, to the extent that licensure, registration, or certification law allows:
(a) A doctor of medicine.
(b) A doctor of osteopathic medicine and surgery.
(c) A doctor of dental surgery.
(d) A doctor of chiropractic.
(e) A doctor of podiatric medicine and surgery.
(f) A physical therapist.
(g) An occupational therapist.
(4) Only a licensed physical therapist, licensed occupational therapist, or licensed practitioner may use procedure codes 97001-97004 to describe the physical medicine and rehabilitation evaluation services. Job-site evaluations may be paid to a licensed occupational therapist, a licensed physical therapist, or a
physician. Job-site evaluations for workers' compensation are by report and are described on the bill using codes WC500-WC600.
(5) If a practitioner performs and bills for physical treatment, then the practitioner shall do all of the following:
(a) Perform an initial evaluation.
(b) Develop a treatment plan.
(c) Modify the treatment as necessary.
(d) Perform a discharge evaluation.
The practitioner shall provide the carrier with an initial evaluation and a progress report every 30 calendar days and at discharge. Documentation requirements are the same as the requirements in R 418.10204(2).
(6) A provider shall report procedure code 97750 to describe a functional capacity evaluation. The carrier shall reimburse a maximum of 24 units or 6 hours for the initial evaluation. Not more than 4 additional units shall be billed for a re-evaluation occurring within 2 months.
(7) Physical medicine modalities are those agents applied to produce therapeutic changes to tissue and include, but are not limited to, thermal, acoustic, light, mechanical, or electric energy. Both of the following apply:
(a) Supervised modalities include procedure codes 97010-97028. These codes do not require direct 1- on-1 patient contact by the provider. These modalities shall be performed in conjunction with a therapeutic procedure including manipulative services or the modalities shall not be reimbursed.
(b) Constant attendance modalities are those procedure codes 97032-97039 that require direct 1-on-1 patient contact by the provider.
(8) Therapeutic procedure codes 97110-97546 are procedures that effect change through the application of clinical skills and services that attempt to improve function. The physician or therapist shall have direct 1-on-1 patient contact.
(9) The following provisions apply to the listed modality services:
(a) Whirlpool shall only be reimbursed when done for debridement or as part of a restorative physical treatment program.
(b) Procedure 97010 is a bundled procedure code and shall not be reimbursed separately.
(c) Not more than 1 deep heat procedure shall be billed on the same date of service for the same diagnosis. Deep heat procedures include diathermy, microwave, ultrasound, and phonophoresis.
(d) Phonophoresis shall be billed using procedure code 97035 with modifier code -22 and shall be reimbursed at the same rate as procedure code 97035, plus $2.00 for the active ingredient used in the process.
(e) Iontophoresis shall include the solution, medication, and the electrodes.
(f) Electrical stimulation shall include the electrodes.
(g) Procedure codes 97032, 97033, and 97035 shall not be reimbursed to a doctor of chiropractic.
(h) Fluidotherapy, a dry whirlpool treatment, shall be reported using code 97022.
R418.10214 Orthotic and prosthetic equipment.
Rule 214. (1) A copy of a prescription by 1 of the following is required for prosthetic and orthotic equipment:
(a) A doctor of medicine.
(b) A doctor of osteopathic medicine and surgery.
(c) A doctor of chiropractic.
(d) A doctor of podiatric medicine and surgery.
(2) Orthotic equipment may be any of the following:
(a) Custom-fit.
(b) Custom-fabricated.
(c) Non-custom supply that is prefabricated or off-the-shelf.
(3) A non-custom supply shall be billed using procedure code 99070, appropriate L-codes or A4570 for a prefabricated orthosis.
(4) An orthotist or prosthetist that is certified by the American board for certification in orthotics and prosthetics, shall bill orthosis and prostheses that are custom-fabricated, molded to the patient, or molded to a patient model. Licensed physical and licensed occupational therapists may bill orthoses using L-codes within their discipline's scope of practice. In addition, a doctor of podiatric medicine and surgery may bill for a custom-fabricated or custom-fit, or molded patient model foot orthosis using procedure codes L3000-L3649.
(5) If a licensed occupational therapist or licensed physical therapist constructs an extremity orthosis that is not adequately described by another
L-code, then the therapist shall bill the service using procedure code L3999. The carrier shall reimburse this code as a "by report” or “BR” procedure. The provider shall include the following information with the bill:
(a) A description of the orthosis.
(b) The time taken to construct or modify the orthosis.
(c) The charge for materials, if applicable.
(6) L-code procedures shall include fitting and adjustment of the equipment.
(7) The health care services division shall publish the maximum allowable payments for L-code procedures in the manual separate from these rules. If an
L-code procedure does not have an assigned maximum allowable payment, then the procedure shall be by report, "BR."
(8) A provider may not bill more than 4 dynamic prosthetic test sockets without documentation of medical necessity. If the physician's prescription or medical condition requires utilization of more than 4 test sockets, then a report shall be included with the bill that outlines a detailed description of the medical condition or circumstances that necessitate each additional test socket provided.
R 418.10905 Billing for physical and occupational therapy.
Rule 905. (1) A physical or occupational therapist shall bill procedure codes 97001-97799. A licensed occupational therapist or
licensedphysical therapist in independent practice shall place his or her signature and license or certification number on the bill.(2) Only a physician, licensed occupational therapist or a licensed physical therapist shall bill for job site evaluation or treatment. The reimbursement for these procedures shall be contractual between the carrier and provider and shall be billed as listed in the following table: Code Descriptor WC500 Job site evaluation; patient specific, initial 60 minutes WC505 each additional 30 minutes, by contractual agreement WC550 Job site treatment; patient specific, initial 60 minutes WC555 each additional 30 minutes, by contractual agreement WC600 Mileage for job site evaluation or job site treatment per mile.
(3) Procedures 97760 and 97761 shall only be reimbursed when billed by a licensed occupational or licensed physical therapist.
(4) Only a licensed physical or occupational therapist shall bill for work hardening services, "by report" or "BR," procedure codes 97545 and 97546.
R 418.10923b Billing for ambulatory surgery center (ASC) or freestanding surgical outpatient facility (FSOF).
Rule 923b. (1) An ASC or FSOF shall be licensed by the Michigan department of community health under part 208 of the code or has an agreement with the centers for Medicare and Medicaid services (CMS) to participate in Medicare. The owner or operator of the facility shall make the facility available
to other physicians, dentists, podiatrists or providers who comprise its professional staff. The following apply:
(a) When a surgery procedure is appropriately performed in the ASC or FSOF and CMS has not assigned a payment code for that procedure, the procedure shall be considered BR.
(b) The ASC or FSOF shall be reimbursed the maximum allowable paid for the payment code, taking into consideration the multiple procedure rule for facilities as defined by CMS.
(2) Billing instructions in this rule do not apply to a hospital-owned freestanding surgical outpatient facility billing with the same tax identification number as the hospital.
(3) An ASC or FSOF shall bill the facility services on the CMS 1500 claim form and shall include modifier SG to identify the service as the facility charge. The place of service shall be "24." The appropriate HCPCS or CPT® procedure code describing the service performed shall be listed on separate lines of the bill.
(4) Modifier 50, generally indicating bilateral procedure is not valid for the ASC or FSOF claim. Procedures performed bilaterally shall be billed on 2 separate lines of the claim form and shall be identified with modifiers, LT for left and RT for right.
(5) A ASC or FSOF shall only bill for outpatient procedures which, in the opinion of the attending physician, can be performed safely without requiring inpatient overnight hospital care and are exclusive of such surgical and related care as licensed physicians ordinarily elect to perform in their private offices.
(6) The payment for the surgical code includes the supplies for the procedure.
(7) Durable medical equipment, the technical component (-TC) of certain radiology services, certain drugs and biologicals that are allowed separate payment under the outpatient prospective payment system (OPPS) will be listed in the manual separate from the rules.
(8) Items implanted into the body that remain in the body at the time of discharge (such as plates, pins, screws, mesh) from the facility are reimbursable when they are designated by CMS as pass through items. These pass through items will be listed in the health care services manual. The facility shall bill implant items with the appropriate HCPCS code that is reimbursable under the OPPS. A report listing a description of the implant and a copy of the facility's cost invoice, including any full or partial credit given for the implant, shall be included with the bill.
(9) Those radiological services that are allowed separate payment under the OPPS will be listed in the manual separate from the rules. When radiology procedures are 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.
(10) At no time shall the ASC or FSOF bill for practitioner services on the facility bill.
(11) When an allowed drug or biological, listed in the manual separate from these rules, is billed by the ASC or FSOF, it shall be listed by the appropriate HCPCS code or CPT medicine code. All of the following apply:
(a) Each drug or biological shall be listed on a separate line.
(b) Units administered shall be listed for each drug or biological.
(c) A dispense fee shall not be billed.
R 418.101002a Conversion factor for practitioner services.
Rule 1002a. (1) The workers' compensation agency shall determine the conversion factor for medical, surgical, and radiology procedures. The conversion factor shall be used by the workers' compensation agency for determining the maximum allowable payment for medical, surgical, and radiology procedures. The maximum allowable payment shall be determined by multiplying the appropriate conversion factor times the relative value unit assigned to a procedure. The relative value units are listed
for the medicine, surgical, and radiology procedure codes in a manual separate from these rules. The manual shall be published annually by the workers' compensation agency using codes adopted from "Physicians' Current Procedural Terminology (CPT®)" as referenced in R 418.10107 (a). The workers’ compensation agency shall determine the relative values by using information found in the "Medicare RBRVS: The Physicians' Guide" as adopted by reference in R 418.10107 (c).
(2) The conversion factor for medicine, radiology, and surgical procedures shall be $50.70 for the year 2010 and shall be effective for dates of service on the effective date of these rules.
R 418.101002b Rescinded
R 418.101003a Reimbursement for dispensed medications.
Rule 101003a. (1) Prescription medication shall be reimbursed at the average wholesale price (AWP) minus 10%, as determined by the Red Book, referenced in R 418.10107, plus a dispense fee. All of the following apply:
(a) The dispense fee for a brand name drug shall be $3.50 and shall be billed with WC700-B.
(b) The dispense fee for a generic drug shall be $5.50 and shall be billed with WC700-G.
(c) Tetanus, Diphtheria, and Acellular Pertussis (Tdap) shall be paid based on AWP minus 10% using the appropriate HCPCS code.
(2) Over-the-counter drugs (OTC's), dispensed by a provider other than a pharmacy, shall be dispensed in 10-day quantities and shall be reimbursed at the average wholesale price, as determined by the Red Book, or $2.50, whichever is greater.
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.
(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. 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.
R 418.101206 Certification of professional health care review program.
Rule 1206. (1) The workers' compensation agency shall certify the carrier's professional health care review program.
(2) A carrier, or the reviewing entity on behalf of the carrier, shall apply to the agency for certification of a carrier's professional health care review program in the manner prescribed by the workers' compensation agency.
(3) A carrier shall receive certification if the carrier or the carrier's review company provides to the agency a description of its professional health care review program and includes all of the information specified in R 418.101204. The workers' compensation agency shall send a copy of the certification of the carrier's review program to the carrier.
(4) The carrier shall submit a copy of “The Carriers Explanation of Benefits” form utilized to notify providers of payment decisions.
R 418.101401 Annual medical payment report.
Rule 1401. (1) Payments for medical services received by injured workers shall be reported to the workers' compensation agency on a form prescribed by the agency entitled "Annual Medical Payment Report." The agency shall provide instruction to the carriers and service companies regarding completion of the form. The annual medical payment report shall cover the periods January 1 through December 31 and shall include all of the following information:
(a) The total number of medical payments for health care services for medical cases, wage loss cases, and the carrier’s total number of worker’s compensation cases in the reporting period.
(b) Medical only cases, defined as those cases where no indemnity was paid, and the total medical payments made by the carrier for those cases.
(c) Wage loss cases, defined as those cases in which wage loss or indemnity was paid, and the total medical payments made by the carrier for those cases.
For the purposes of this annual medical payment report, once wage loss benefits are paid, then the case shall always be reported as wage loss.
(2) The annual medical payment report shall be due in the agency by February 28 of each year. The report shall not include travel expenses, payments for independent medical examinations, vocational rehabilitation, or rehabilitation case management expenses.
(3) A carrier, self insured, or group shall submit required forms electronically either directly or through a third party vendor, to the agency at such time as the director deems appropriate. The electronic forms required are both of the following:
(a) Certification of a carrier’s professional health care review program (form WC590).
(b) Annual medical report (WC406).
