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DE P ARTMEN T OF CONSU MER AND INDUS TRY SER VICES BURE AU OF WORKERS ' DISABILIT Y COMP ENS ATIO N WORKER 'S COMP ENS ATIO N HE ALTH CARE SER VICES
Filed with th e Secretar y of Stat e on
These ru les tak e effect 7 days after filing with th e Secretar y of Stat e
(By auth ority con ferr ed on th e bur eau of work er 's disability com pensat ion by sections 205 an d 315 of 1969 PA 317 , section 33 of 1969 PA 306 , Execut ive Reorgan izat ion Order No. 1982 -2, Execut ive Reorgan izat ion Order No. 1986 -3, an d Execut ive Reorgan izat ion Order No. 1990 -1, MCL 418 .205 , 418 .315 , 24.233 , 18.24, 418 .1, an d 418 .2
R 418 .10107 , R 418 .1010115 , R 418 .10116 , R 418 .10117 , R 418 .10202 , R 418 .10205 , R
418 .10901 , R 418 .10904 , R 418 .10912 , R 418 .10916 , R 418 .10923 , an d R 418 .101002 , of th e
Michigan Administrat ive Code ar e am ended , R 418 .10909 an d R 418 101005 ar e added to th e code, an d R 418 .10405 , R 418 .10406 , R 10407 , R 418 .10411 , R 418 .10415 , R 418 .10501 ,
R 418 .10502 , R 418 .10503 , an d R 418 .10918 of th e Michigan Administrat ive Code ar e rescinded to read as follows :
P ART 1. GENER AL P ROVISIONS
R 418 .10107 Sou rce documents .
Rule 107 . The followin g docum ent s ar e adopted by reference in th ese ru les an d ar e available for inspection at , or pur cha se from, th e bur eau of work ers' disability com pensat ion, health car e services division, P.O. Box 30016 , Lan sing, Michigan 48909 , at th e cost s listed or from th e organ izat ions listed:
(a) "Curr ent Pr ocedura l Term inology, CPT 200
12," stan dar d edition, copyr ight October 20001, published by th e American Medi cal(b) "Medi car e's Nat iona l Level II Codes , HCPCS, 200
12," MILL EN IUM EDITIO N, copyright November 20001, published by th e American Medi cal Ass ociat ion, P.O. Box 7046 ,(c) "RBRVS, Fee Schedule: A Plain En glish Guide," 1999 edition, published by Un ited Commun icat ions Group, 11300 Rock ville Pike, Suite 1100 , Rock ville, MD 20852 -3030 .
(d)“Medi car e RBRVS 200
12: The Ph ysician s’ Guide,” published by The American Medi cal Ass ociat ion, 515 North Stat e Str eet, Chicago Il, 60610 , order(e) "Int ernat iona l Classificat ion of Dise ases , ICD-9-CM 2002 "
n inth r evisi onMILL EN IUM EDITIO N, copyright 20001, American Medi cal Ass ociat ion, P.O. Box 7046 , 515 N Stat e Str eet, Chicago, IL 60610 , order #OP 068101B E W2BLC , 1-800 -621 -8335 . The publicat ion ma y be pur cha sed at a cost of $59 .95, plus $8.95 shipping an d han dling,atAS OF th e t ime of adoption of th ese ru les.(f) "200
12 Dru g Topics Red Book," published by Medi cal Economics Compan y Inc., Five Para gon Drive, Mont vale, NJ 07645 -1742 , 1-800 -678 -5689 . The publicat ion ma y be pur cha sed at a cost of $64 .95, plus $7.95 for shipping an d han dling,atAS OF th e t ime of adoption of th ese ru les.(g) "Michigan Un iform Billing Manua l," developed in cooperat ion with th e American Hospita l Ass ociat ion's Nat iona l Un iform Billing Comm itt ee, published by Michigan Health an d Hospita l Ass ociat ion, 6215 West St.J osep h Highway, Lan sing, MI 48917 , 517 -886 - 8366 . As of th e t ime of adoption of th ese ru les, th e cost of th e publicat ion is $135 .00, plus 6% sales ta x.
R 418 .10115 RES P ONS IBILIES ; of
Iinsu red emp loye rr espons ibilityOR SE LF- INSURER .Rule 115 .(1) AN
T h einsur ed employer sha ll do all of th e followin g:(a) Pr omptly file form 100 ,
Eemployer’sBbasicRreport ofIinjur y, to report an injur y that results in 7 or more days of disability, specific loss, or death , with th e bur eau an d it s insur er.(b) Pr omptly notify it s insur er of th e cases that do not result in 7 or more days of disability, specific loss, or death .
(c) Pr omptly in form th e provider of th e nam e an d address of it s insur er or th e des ignat ed agent of th e insur er to whom health car e bills should be sent .
(d) If an insur ed employer receives a bill, th en th e insur ed employer sha ll promptly tran smit th e provider’s bill an d docum entat ion to th e insur er or th e des ignat ed agent of th e insur er regar ding a relat ed injur y or illness .
(2) FOR THE PU RPOSES OF THIS RULE, A SELF-INSUR ER SHALL PROMPTLY REP ORT ALL EMPLOYEE WORK -RELATED IN J URIES TO THE IR DESIGN ATED AGEN T, UN LESS THE Y ARE SELF-ADMI NIS TERED.
(A) UN LESS SELF-ADMI NIS TERED, A SELF-INSUR ER RECEIVING A BILL FOR A MEDIC AL SERVICE SHALL FORWARD THE BILL TO THE IR DESIGN ATED AGEN T FOR PROCESSING AND SHALL IN FORM THE MEDIC AL PROVIDER OF THE ADDR ESS WHE RE FU TURE BILLS SHALL BE SEN T.
R 418 .10116 P rovide r respons ibiliti es .
Rule 116 . (1) A provider sha ll do both of th e followin g:
(a) Pr omptly bill th e carr ier or th e carr ier’s des ignat ed agent after th e dat e of service.
(b)
Pr ovide r eq u ir ed d ocum e ntat ion of se r vices , w h ich s ha ll a ccom p an ySUBMIT THE BILL FOR THE MEDIC AL SERVICES PROVIDED TO TREAT AN IN J URED WORK ER ON THE PROPE R CLAIM FORM,th e billto th e WORK ERS’ COMPEN SATIO N carr ier or th e carr ier ’s des ignat ed agent AND SHALL ATTACH THE DOCUMEN TATIO N REQUI RED IN PART 9 OF THE SE RULES.(C) IF A CARRI ER REQUES TS THE PROVIDER TO SEN D DUP LIC ATED COPIES OF THE DOCUMEN TATIO N REQUI RED IN PART 9 OR ADDITIO NAL MEDIC AL RECORDS NOT REQUI RED BY THE SE RULES, THEN THE CARRI ER SHALL REIMBURS E THE PROVIDER FOR THE COPYING CHARGES IN ACCORD WITH R 418 .10118 .
(2) If th e provider ha s not received payment with in 30 days of submitt ing a bill, th en th e provider sha ll RESUBMIT THE BILL TO THE CARRI ER AND ADD A 3% LATE FEE
se n d a se con d cop y of th e bill an d ma y a dd a 3 % lat e fee.R 418 .10117 Carri er respons ibiliti es .
Rule 117 . (1) The carr ier or it s des ignat ed agent sha ll assur e that a billing form is com pleted properly befor e mak ing payment .
(2) A carr ier ma y des ignat e a th ird part y to receive provider bills on it s beha lf.
W h e nIF a carr ier instru cts th e provider to send th e medical bills directly to th e th ird part y, THEN th e 30-day limit of th is ru le begins when th e th ird part y receives th e bill.(a )The carr iers ha llbeIS resp onsible for for war ding bills an d medical docum entat ion when th ere is a th ird part y reviewi ng medical bills for th e carr ier.(4) A carr ier or des ignat ed agent sha ll mak e payment of an adjusted bill or port ion of an adjusted bill with in 30 days of receipt of th e properly submitt ed bill. If a carr ier or des ignat ed agent rejects a bill in it s ent irety, th en th e carr ier or des ignat ed agent sha ll notify th e provider of
thatTHE rejection with in 30 days after receipt of a properly submitt ed bill.R 418 .10202 Eval ua tio n and managemen t se rvices .
Rule 202 . (1)
E va luat ion an d mana ge m e nt se r vices in clu de office vis it s , h osp ita l vis it s ,an d con s u ltat ion s . E va luat ion an d mana ge m e nt se r vices or office vis it s ar e cla ss ifie d a s th ep la ce of se r vice an d ma y be des cr ibe d a s a n ew p at ie nt or s u bseq u e nt or follow -u p vis it .(2)) T h e ma ximum a llow a ble p a ym e nt for an eva luat ion an d mana ge m e nt se r vice of ap at ie nt s ha ll in clu de a ll of th e followin g:(a)) An exam inat ion. PROCEDURE CODE 97010 PE RFORMED IN CONJ UN CTIO N WITH AN OFF ICE VISIT SHALL NOT BE RE IMBURS ED AS A SEP ARATE PROC EDURE.(b)T h e eva luat ion an d mana ge m e nt code des cr ibi n g th e exam inat ion , in clu des th e gr ossa ssess m e nt of th e ran ge of m ot ion of joint s . Pr oced ur e codes des cr ibi n g th e ran ge of m ot ionse r vices , 95851 -98582 , s ha ll on ly be billed a s a sep arat e p r oced ur e t o th e w ork e r ’scom pe n s at ion carr ie r w h e n th e ran ge of m ot ion a ssess m e nt is a b n orma l an d th e ran ge ofm ot ion m e a s ur e m e nt s ar e tak e n with a gon iom e t e r . I f billi n g 95851 -95852 , th e p r ovide rs ha ll in clu de a r ep ort d ocum e nt in g m e a s ur e m e nt s tak e n .(c)(2) Minor medical an d sur gical suppliesthat ar erout inely used by th e pra ct it ioner or health car e organ izat ion in th e office visit sha ll not be billed sep arat ely.(3)Supplies, or oth er services, over an d above th ose usua lly incidenta l to an office visit or oth er out pat ient visit for th e evaluat ion an d mana gement of a pat ient sha ll be billed sep arat ely un der procedur e code 99070 .(4)IF AN OFF ICE VISIT IS PE RFORMED OUTSID E OF THE PROVIDER’S NORMAL BUSINESS HOURS, THE PROVIDER MAY BILL THE ADD ON PROCEDURE CODES DESCRIBING AN OFF ICE VISIT PE RFORMED AFTER HOURS OR ON SUND AYS OR HOLID AYS. A PROVIDER MAY BILL ADD ON PROCEDURE CODE 99050 IN ADDITIO N TO THE EVALUATIO N AND MANAGEMEN T SERVICE, IF a servicethatis(6) S u b ru le s (3 ) an d (4 ) of th is ru le s ha ll on ly a pp ly if a p r ovide r pe r form s a se r vice a ft e r th ep ra ct it ion e r ’s or h e a lth car e or gan izat ion ’s s ch ed u le d b u s in ess h our s .(75) A procedur e that is norma lly part of an exam inat ion or evaluat ion sha ll not be billed indepe ndent ly.
(A) RANGE OF MOTIO N SHALL NOT BE REIMBURS ED AS A SEP ARATE PROCEDURE UN LESS THE PROCEDURE IS MEDIC ALLY NE CESSARY AND APP ROPRIATE FOR THE IN J URED WORK ER’S CONDITIO N AND DIAGNOSIS .
(
86) The ma ximum a llowable payment for th e evaluat ion an d mana gement service sha ll be determ ined by mu lt iplying th e relat ive value UNI T, RVU, assigned to th e procedur e code, t imes th e con version factor listed in th e reimbur sement section of th ese ru les.(9) I f coun se lin g or coor d inat ion of car e , or b oth , exceed 50 % of th e p h ys ician an d p at ie nte n count e r or th e p h ys ician , p at ie nt , an d fam ily e n count e r , or b oth , t im e is th e k ey orcontr olli n g fa ct or that de t e rm in es th e eva luat ion an d mana ge m e nt se r vice level. T h eext e nt of coun se lin g an d coor d inat ion of car e , or b oth , s ha ll be d ocum e nt ed in th e r e cor d .(10 )(7) The level of an office visit or oth er out pat ient visit for th e evaluat ion an d mana gement of a pat ient is not guarant eed an d ma y chan ge from sess ion to sess ion. The level of service sha ll be con sistent with th e type of prese nt ing com plaint an d support ed by docum entat ion in th e recor d.(12 )(9) The carr ier sha ll not reimbur se th e provider for pr oced ur e codes 90782 -90799 , administrat ion of th era peut ic injections, if billed in con jun ct ion with an evaluat ion an d mana gement service. The medicat ion administered in th e th era peut ic injection sha ll be(13 )(10) The provider ma y bill immun izat ion pr oced ur e codes in addition to th e evaluat ion an d mana gement procedur e code. If th e provider bills an immun izat ion, THEN th e vaccine is described with pr oced ur e codes 90476 -90748 , an d th e administrat ion of th e va ccin e is des cribed with pr oced ur e code 90471 or 90472 . The carr ier sha ll reimbur se th e va ccin e at th e avera ge wholesale price of th e va ccin e plus th e cost of administrat ion billed with pr oced ur e codes 90471 or 90472 . Pr oced ur e code 90471 is reimbur sed at $5.00 an d pr oced ur e code 90472 is reimbur sed at $7.50.R 418 .10205 Consu lt ation se rvices .
Rule 205 . (1) An att ending physician , carr ier, th ird-part y administrat or, or th e injur ed work er ma y request a con sultat ion. A physician specialist sha ll provide con sultat ions using pr oced ur e codes 99241 -99275 to describe th e service.
(2) The carr ier ma y request a provider oth er than th e tr eat ing pra ct it ioner to perform a con firmat ory con sult. The physician spe cialist per form ing th e con firmat ory con sult sha ll bill pr oced ur e codes 99271 -99275 , defined in curr ent pr oced ura l term inology, an d sha ll be subject to th e ma ximum payment allowan ce as defined in th e reimbur sement section of th ese ru les.
(3) If a specialist per form s diagnostic pr oced ur es or testing in addition to th e con sultat ion, THEN th e specialist sha ll bill th e appropriat e pr oced ur e code from curr ent pr oced ura l term inology. The carr ier sha ll reimbur se th e testing pr oced ur es in a ccor dan ce with th ese ru les.
(4)
I f a p h ys ician spe cia lis t pe r form s a follow-u p con s u ltat ion , th e se r vices s ha ll be des cr ibe d u s in g p r oced ur e codes 99261 -99263 . I f, a ft e r pe r form in g th e in it ia l con s u ltat ion , a p h ys ician spe cia lis t a ss um es r esp on s ibili t y for mana ge m e nt of a p ort ion or a ll of th e p at ie nt ’s con d it ion or con d it ion s , th e p h ys ician spe cia lis t s ha ll n ot u se th e follow-u pcon s u ltat ion codes t o des cr ibe office vis it s . T h e p h ys ician spe cia lis t s ha ll u se p r oced ur ecodes 99211 -99215 for follow -u p car e w h e n a ss um in g mana ge m e nt of th e p at ie nt ’scon d it ion .R 418 .10405
I n jec tio ns .Resc inded .R u le 405 . (1 ) I f 3 or m or e in je ct ion s int o joint s or b ur s a e ar e billed with in 1 m onth , th ebill s ha ll in clu de d ocum e ntat ion of m edi ca l n e cessi t y.(2 ) An in je ct ion p r oced ur e s ha ll in clu de a ll of th e followin g:(a ) I ntr od u ct ion of n eedles or cath e t e r s .(b)L oca l an es th esi a .(c)N e cess ar y p r e -in je ct ion an d p os t -in je ct ion car e spe cifica lly r elat ed t o th e in je ct ion p r oced ur e.R 418 .10406 In tegumen tary system ; w ound repa ir . Resc inded .
R u le 406 . (1 ) T h e p r ovide r s ha ll bill a w oun d r ep a ir a s follows :(a)) T h e p r ovide r s ha ll m e a s ur e an d r e cor d in ce nt im e t e r s , an d des cr ibe th e r ep a ir ed w oun da s cur ve d , an gu lar , or s t ellat e.(b)T h e woun d r ep a ir s ha ll be cla ss ifie d a s s im p le, int e rm edi at e orcom p lex. I f mu lt ip le w oun ds ar e r ep a ir ed , th e le n gth s in e a ch cla ss ificat ion an d fr om a llanat om ic s it es ar e gr ou ped t oge th e r int o th e s am e code des cr ip t or an d r ep ort ed a s a s in gleit em .(c)I f m or e than 1 cla ss ificat ion of woun d is r ep a ir ed , th e n th e p r ovide r s ha ll lis t th e m os tcom p licat ed woun d r ep a ir a s th e p r imar y p r oced ur e an d th e le ss com p licat ed a s th ese con d ar y p r oced ur e , u s in g m od ifie r -51 .(2)) T h e I nt egum e ntar y r ep a ir in clu des s ur gica l cle an s in g an d tr imm in g of th e w oun d edgesan d th e carr ie r s ha ll n ot r eim b ur se a s an sep arat e p r oced ur e .(3)S im p le lig at ion of ve sse ls in an ope n w oun d s ha ll be con s ide r ed a s p art of an y w oun dclos ur e , an d th e carr ie r s ha ll n ot r eim b ur se a s a sep arat e p r oced ur e .(4)) S im p le expl orat ion of n e r ve s , blood ve sse ls , or t e n d on s exp osed in an ope n w oun d s ha llbe con s ide r ed p art of th e esse nt ia l tr e atm e nt of th e w oun d , an d is n ot an in depe n de ntp r oced ur e un le ss a pp r ecia ble d isse ct ion is r eq u ir ed .(5)T h e r ep a ir of n e r ve s , blood ve sse ls , an d t e n d on s s ha ll be con s ide r ed a s p art of th e p r imar y p r oced ur e , excep t w h e n th e w oun d is com p lex, in w h ich ca se m od ifie r code -51 a pp lie s .(6)) E xcis ion an d r ep a ir by a d ja ce nt t iss u e tran s fe r , or b oth , or r e arran ge m e nt , Z-p la s t y , V-Y p la s t y , W-p la s t y , r otat ion fla p , a d van ced fla p , or d ou ble ped icle fla p , s ha ll a pp ly on ly if th e p r oced ur e lis t ed mu s t be de vel oped by th e p ra ct it ion e r t o a ccom p lis h th e r ep a ir , an d s ha ll n ot a pp ly w h e n d ir e ct clos ur e or r e arran ge m e nt of traumat ic w oun ds in cide nta lly r es u lt in th ese con figurat ion s .R 418 .10407 Deb ridement . Resc inded .
R u le 407 . (1 ) Deb r ide m e nt s ha ll be con s ide r ed an in depe n de nt p r oced ur e on ly if gr osscontam inat ion r eq u ir es p r olon ge d cle an s in g, if a pp r e cia ble am ount s of de vita lize d orcontam inat ed t iss u e ar e r e m ove d , or if deb r ide m e nt is pe r form ed with out imm edi at ep r imar y clos ur e .(2 ) I f th e p ra ct it ion e r bills a deb r ide m e nt p r oced ur e code , th e n th e ope rat ive r ep ort s ha llin clu de a fu ll des cr ip t ion of th e deb r ide m e nt . I f th e ope rat ive r ep ort d oes n ot in clu de a fu lldes cr ip t ion of th e deb r ide m e nt , th e n th e deb r ide m e nt p r oced ur e s ha ll n ot be p a id .R 418 .10411 Casting and st rapping procedu res . Resc inded .
R u le 411 . (1 ) A ca s t in g or s tra pp in g p r oced ur e code s ha ll in clu de th e s u pp lie s an d th ea pp licat ion an d r e m ova l of th e ca s t or s tra pp in g w h e n r e n de r ed by th e s am e p ra ct it ion e r .(2)) Pr oced ur e codes 29000 -29740 a pp ly a s follows :(a)) T h e ca s t a pp licat ion or s tra pp in g is a r epl a ce m e nt p r oced ur e u sed d ur in g or a ft e r th epe r iod of follow-u p car e.(b)) T h e ca s t a pp licat ion or s tra pp in g is an in it ia l se r vice pe r form ed with out a r es t orat ivetr e atm e nt p r oced ur e or p r oced ur es t o s ta bilize or p r ot e ct a fra ctur e , in jur y, or d is locat ion .T h e ca s t a pp licat ion or s tra pp in g ma y a ls o be u sed t o a ffor d com fort t o a p at ie nt .(3)) Res t orat ive tr e atm e nt p r oced ur e or p r oced ur es r e n de r ed by an oth e r p h ys ician followin gth e a pp licat ion of th e in it ia l ca s t , sp lint , or s tra p ma y be r ep ort ed with a tr e atm e nt offra ctur e an d or d is locat ion code .(4)A p h ys ician w h o a pp lie s th e in it ia l ca s t , s tra p , or sp lint an d a ls o a ss um es a ll of th e s u bseq u e nt fra ctur e , d is locat ion , or in jur y car e s ha ll n ot u se th e a pp licat ion of ca s t s an d s tra pp in g codes a s an in it ia l se r vice, be cau se th e fir s t ca s t , sp lint , or s tra p a pp licat ion isin clu ded in th e tr e atm e nt of fra ctur e an d d is locat ion codes .(5)A t e m p orar y ca s t , sp lint , or s tra p is n ot con s ide r ed p art of th e p r eope rat ive car e, an d th e u se of m od ifie r code -56 is n ot a pp lica ble . Add it iona l eva luat ion an d mana ge m e nt se r vices ar e r ep orta ble on ly if furth e r s ign ificant ide nt ifia ble se r vices ar e p r ovided at th e t im e of th e ca s t a pp licat ion or s tra pp in g.(6)) I f a ca s t a pp licat ion or s tra pp in g is p r ovided a s an in it ia l se r vice (e .g., ca s t in g of asp ra in ed ank le or kn ee ) in w h ich n o oth e r p r oced ur e or tr e atm e nt (e .g., s ur gica l r ep a ir ,r ed u ct ion of a fra ctur e or joint d is locat ion ) is pe r form ed or is expe ct ed t o be pe r form ed by ap h ys ician r e n de r in g th e in it ia l car e on ly, u se th e ca s t in g, s tra pp in g code in a dd it ion t o aneva luat ion an d mana ge m e nt code a s a pp r op r iat e .H is t or y: 2000 MR 6 , E ff. M a y 11 , 2000 .R 418 .10415 Sta rred (*) su rgica l procedu res . Resc inded .
R u le 415 . (1 ) Wh e n th e s tarr ed (*) s ur gica l p r oced ur e is carr ie d out at th e t im e of anin it ia l vis it (n ew p at ie nt ) an d th is p r oced ur e con s t itut es th e ma jor se r vice at that vis it ,p r oced ur e code 99025 is lis t ed in p la ce of th e u s ua l in it ia l vis it a s an a dd it iona l se r vice .(2)) Wh e n th e s tarr ed (*) s ur gica l p r oced ur e is carr ie d out at th e t im e of an in it ia l ores ta blis h ed vis it in volvi n g s ign ificant ide nt ifia ble se r vices , th e a pp r op r iat e vis it is lis t edwith m od ifie r -25 in a dd it ion t o th e s tarr ed (*) s ur gica l p r oced ur e an d it s follow-u p car e.(3)) Wh e n th e s tarr ed (*) s ur gica l p r oced ur e r eq u ir es h osp ita liz at ion , an a pp r op r iat eh osp ita l vis it is lis t ed in a dd it ion t o th e s tarr ed (*) s ur gica l p r oced ur e an d it s follow-u p car e.(4 ) A s tarr ed (*) s ur gica l p r oced ur e , m in or s ur gica l p r oced ur e , s ha ll in clu de th e se r vicesspe cifie d in R 418 .401 an d th e 10 -d a y follow -u p pe r iod for th e des ignat ed p r oced ur e code .(5)) Wh e n follow -u p d a ys ar e n ot in clu ded in th e s tarr ed (*) s ur gica l p r oced ur e , a llp os t ope rat ive car e is a dded on a se r vice-by-se r vice b a s is .(6)Com p licat ion s ar e a dded on a se r vice-by-se r vice b a s is (a s with a ll s ur gica l p r oced ur es ).P ART 5. RADIOLOG Y, RADIATIO N THER AP Y, AND NU CLEAR MED ICINE
R 418 .10501 Comp le te radio logic procedu res . Resc inded .
R u le 501 . T h e com p le t e ra d iologic p r oced ur e d oes n ot in clu de th e cos t of ra d iois ot opes .T h e com p le t e p r oced ur e s ha ll in clu de th e cos t of a ll of th e followin g, w h e r e a pp lica ble , withr espe ct t o th e ra d iologica l se r vice:(a)) P e r s onn el. (b) M at e r ia ls .(c) Contra s t m edi a , excep t for ga d olin ium an d low os m olar contra s t m edi um , an d d ru gs .(d ) F ilm or xe r ogra p h .(e)Sp a ce.(f)E q u ip m e nt .(g)S u pe r vis ion .(h)) I nt e r p r e tat ion .(i)I n je ct ion p r oced ur es .R 418 .10502 Supe rvision and in te rpre tatio n procedu res . Resc inded .
R u le 502 . (1 ) I f a ra d iology p r oced ur e is pe r form ed by t w o p h ys ician s , th e ra d iologicp ort ion of th e p r oced ur e is des ignat ed a s th e “ra d iologica l s u pe r vis ion an d int e r p r e tat ion .”(2 ) I f a p h ys ician pe r form s th e p r oced ur e an d p r ovides ima gin g s u pe r vis ion an dint e r p r e tat ion , th e n a com binat ion of p r oced ur e codes out s ide th e 70000 se r ie s of codes isu sed by th e p r ovide r t o r ep ort th e se r vice .(3)I f an x-ra y is tak e n in a h osp ita l, th e n th e ra d iologis t s ha ll be p a id th e p r ofessi ona lcom p on e nt of th e p r oced ur e code an d th e h osp ita l s ha ll be p a id th e t e chn ica l com p on e nt .(4)) T h e carr ie r s ha ll r eim b ur se for a com p le t e ra d iology p r oced ur e pe r form ed an d billed byan in depe n de nt ra d iology clin ic or a d oct or of ch ir op ra ct ic, d oct or of de nta l s ur ge r y, d oct or ofm edi cin e, d oct or of os t eop ath y, or d oct or of p od iatr y in th e p ra ct it ion e r ’s office.(5)) T h e carr ie r s ha ll n ot p a y for r eview of an x-ra y by a p ra ct it ion e r oth e r than th era d iologis t or th e p ra ct it ion e r w h o pe r form s th e com p le t e ra d iology p r oced ur e . I f a p r ovide rr eviews an x-ra y d ur in g an eva luat ion an d mana ge m e nt se r vice , th e n th e carr ie r s ha ll n otp a y for r eview of th e x-ra y a s a sep arat e p r oced ur e , be cau se th e eva luat ion an dmana ge m e nt se r vice in clu des r eview of t es t s an d m e a s ur e m e nt s .R 418 .10503 Injec tio n procedu res . Resc inded
R u le 503 . An in je ct ion p r oced ur e for ra d iogra p h y s ha ll in clu de a ll u s ua l p r e -in je ct ionan d p os t -in je ct ion car e spe cifica lly r elat ed t o th e in je ct ion p r oced ur e n e cess ar y for loca lan es th esi a , p la ce m e nt of n eedle or cath e t e r , an d in je ct ion of contra s t m edi a .R 418 .10901 Gene ral Informa tio n.
Rule 901 . (1) All health car e pra ct it ioners an d health car e organ izat ions, as defined in th ese ru les, sha ll submit char ges on th e proper claim form as specified in th is ru le. Copies of th e claim form s an d instru ct ion for com pletion for each form sha ll be published sep arat e from th ese ru les in a manua l distr ibut ed by th e health car e services division of th e bur eau . CHARGES SHALL BE SUBMITT ED AS FOLLOWS :
(a) A pra ct it ioner sha ll submit char ges on th e HCFA 1500 claim form .
(b) A doct or of dent istr y sha ll submit char ges on a stan dar d denta l claim form approved by th e American
Ddenta lAass ociat ion.(c) A pharma cy, oth er than an inpat ient hospita l, sha ll submit char ges on an invoice or a pharma cy un iversal claim form .
(d) A hospita l-own ed occu pat iona l, industr ial clinic, or office pra ct ice sha ll submit char ges on th e HCFA 1500 claim form .
(e) A hospita l billing for a pra ct it ioner service sha ll submit char ges on a HCFA 1500 claim form .
(f) Ancillar y service char ges sha ll be submitt ed on th e HCFA 1500 claim form for
h om eh e a lth ,DURABLE MEDIC AL EQUIP MEN T AND SU PP LIES, L-CODE PROCEDURES, am bulan ce, vision, an d hear ing services. CHARGES FOR HOME HE ALTH SERVICES SHALL BE SUBMITT ED ON THE UB-92 CLAIM FORM.(g) A shoe supplier or wig supplier sha ll submit char ges on an invoice.
(2) A provider sha ll submit all bills to th e carr ier with in
on e1 year of th e dat e of service for con siderat ion of payment , except in cases of litigat ion or subrogat ion.(3) A properly submitt ed bill sha ll include ALL OF th e followin g appropriat e docum entat ion:
(a) A copy of th e medical report for th e initial visit.
(b) An updat ed progress report if tr eatm ent exceeds 60 days.
(c) A copy of th e initial evaluat ion an d a progress report every 30 days of physical tr eatm ent , physical or occu pat iona l th era py, or man ipulat ion services.
(d) A copy of th e operat ive report or office report if billing sur gical pr oced ur e codes 10040 - 69990 .
(e) A copy of th e an esth esia recor d if billing an esth esia codes 00100 -01999 .
(f) A copy of th e ra diology report if submitt ing a bill for a ra diology service a ccom pan ied by modifier -26.
(g) A report describing th e service if submitt ing a bill for a “by report ” pr oced ur e.
(h) A copy of th e medical report if a modifier is applied to a pr oced ur e code to explain unu sua l billing circum stan ces.
R 418 .10904 P rocedu re codes and mod ifiers.
Rule 904 . (1) A health car e service sha ll be billed with pr oced ur e codes adopted from “Curr ent Pr ocedura l Term inology” or “HCPCS, Medi car e’s Nat iona l Level II Codes ,” as referenced in R 418 .10107 of th ese ru les. PROCEDURE
T h esecodes FROM “CURREN T PROCEDURAL TERMI NOLOG Y” sha ll not be included in th ese ru les, but sha ll be listed in a sep arat e manua l published by th e bur eau . Refer to “Curr ent Pr ocedura l Term inology” for stan dar d billing instru ct ions, except where oth erwise noted in th ese ru les.(A) A PROVIDER BILLI NG SERVICES DESCRIB ED WITH PROC EDURE COD ES FROM “MEDIC ARE’S NATIO NAL LEVEL II CODES” SHALL REFE R TO THE PU BLIC ATIO N AS ADOPTED BY REFE REN CE IN R 418 .10107 FOR CODI NG IN FORMATIO N.
(2) The followin g an cillar y service providers sha ll bill codes from “HCPCS, Medi car e’s Nat iona l Level II Codes ” as referenced in R 418 .10107 of th ese ru les to describe th e an cillar y services:
(a) Ambulan ce providers.
(b) Cert ified orth otists an d prosth etists.
(c) Medi cal suppliers, including expe ndable an d dura ble equipment . (d) Hear ing aid vendors an d suppliers of prosth etic eye equipment .
(3) A home health agency.
s ha ll bill a code fr om th e followin g ta ble t o des cr ibe nur s in ga ssess m e nt s , sk ille d car e, or h om e h e a lth a ides pe r h our .WC Code Des cr ip t ionH O100 Sk ille d nur s in g car eH O300 Nurs in g car e eva luat ionH O550 H om e h e a lth a ide pe r h ourH 9999 N ot oth e r wise cla ss ifie d(4) If a pra ct it ioner per form s a pr oced ur e that cann ot be des cribed by one of th e listed CPT or HCPCS codes , th en th e pra ct it ioner sha ll bill th e un listed pr oced ur e code . An un listed pr oced ur e code sha ll only be reimbur sed when th e service cann ot be properly des cribed with a listed code an d th e docum entat ion support ing medical necessi ty includes ALL OF th e following:
(a) Description of th e service.
(b) Docum entat ion of th e t ime, effort , an d equipment necess ar y to provide th e car e.
(c) Complexity of symptoms.
(d) Pert inent physical findings.
(e) Diagnosis.
(f) Treatm ent plan .
(5) The provider sha ll add a modifier code, FOUN D IN APPEN DIX A OF THE CPT PU BLIC ATIO N AS ADOPTED BY REFE REN CE IN R 418 .10107 ,
t o th e e n d ofFOLLOWI NG th e corr ect pr oced ur e codet odescribeING unu sua l circum stan ces ar ising in th e tr eatm ent of a cover ed injur y or illnessor t o des cr ibe th e p ra ct it ion e r w h o pe r form s th ese r vice.(a)
I fWHEN a modifier code is applied to DESCRIB E a pr oced ur e,th e n th eA report DESCRIBING THE UNUSU AL CIRC UMST ANCES sha ll BE included WITH THECHARGES SUBMITT ED TO THE CARRI ER
th e cir cum s tan ce r eq u ir in g th e u se of am od ifie r code.(c)(6) APP LIC ABLE MODI FIERS FROM TABLE 10904 SHALL BE ADDED TO THE PROC EDURE COD E TO DESCRIB E THE TYPE OF PRACTITIO NE R PE RFORMI NG THE SERVICE. THE REQUI REDMmodifier codes FOR DESCRIBING THE PRACTITIO NE R ar e as follows:Table 10904 Modifier Codes
-21 Pr olon ge d eva luat ion an d mana ge m e nt se r vice : Wh e n th e fa ce-t o-fa ce,floor , or un it se r vice or se r vices p r ovided ar e p r olon ge d or oth e r wisegr e at e r than that u s ua lly r eq u ir ed for th e h igh es t level of eva luat ionan d mana ge m e nt se r vice with in a give n cat egor y, it s ha ll be ide nt ifie dby a dd in g m od ifie r -21 t o th e eva luat ion an d mana ge m e nt code .-22 Unusua l se r vices : Wh e n th e se r vice or se r vices p r ovided is gr e at e r thanthat u s ua lly r eq u ir ed for th e lis t ed p r oced ur e , it s ha ll be ide nt ifie d bya dd in g m od ifie r -22 t o th e u s ua l p r oced ur e code .-23 Unusua l an es th esi a : O cca s iona lly, a p r oced ur e w h ich u s ua lly r eq u ir eseith e r n o an es th esi a or loca l an es th esi a , be cau se of unu s ua lcir cum s tan ces , mu s t be d on e un de r ge n e ra l an es th esi a . T h e p r oced ur es ha ll be r ep ort ed by a dd in g m od ifie r -23 t o th e p r oced ur e code of th eb a s ic se r vice.-24 Unr elat ed eva luat ion an d mana ge m e nt se r vice by th e s am e p h ys iciand ur in g p os t ope rat ive pe r iod : I f th e p h ys ician n eeds t o in d icat e that aneva luat ion an d mana ge m e nt se r vice w a s pe r form ed d ur in g ap os t ope rat ive pe r iod for a r e a s on or r e a s on s unr elat ed t o th e or igi na lTable 10904 Modifier Codes
p r oble m , th e cir cum s tan ce s ha ll be r ep ort ed by a dd in g th e m od ifie r -24 .-25S ign ificant , sep arat ely ide nt ifia ble eva luat ion an d mana ge m e nt se r viceby th e s am e p h ys ician on th e s am e d a y of th e p r oced ur e or oth e r se r vice :I f th e p h ys ician n eeds t o in d icat e that on th e d a y a p r oced ur e or se r viceide nt ifie d by a C P T code w a s pe r form ed , th e p at ie nt ’s con d it ion r eq u ir eda s ign ificant , sep arat e ide nt ifia ble eva luat ion an d mana ge m e nt se r vicea b ove an d bey on d th e oth e r se r vice p r ovided or bey on d th e u s ua lp r e ope rat ive an d p os t ope rat ive car e a ss ociat ed with th e p r oced ur e thatw a s pe r form ed , th e cir cum s tan ce s ha ll be r ep ort ed by a dd in g th em od ifie r -25 t o th e a pp r op r iat e level of eva luat ion an d mana ge m e ntse r vice . M od ifie r -25 s ha ll n ot be u sed t o r ep ort an eva luat ion an dmana ge m e nt se r vice that r es u lt s in a de cis ion t o pe r form s ur ge r y.-26 Pr ofessi ona l com p on e nt : Ce rta in p r oced ur es ar e a com binat ion of ap r ofessi ona l com p on e nt an d a t e chn ica l com p on e nt . Wh e n th e p h ys iciancom p on e nt is r ep ort ed sep arat ely, th e se r vice s ha ll be ide nt ifie d bya dd in g th e m od ifie r -26 t o th e u s ua l p r oced ur e code .-50 Bilat e ra l p r oced ur e : Un le ss oth e r wise ide nt ifie d in th e lis t in gs , bilat e ra lp r oced ur es that ar e pe r form ed at th e s am e ope rat ive sess ion s ha ll beide nt ifie d by a dd in g m od ifie r -50 t o th e a pp r op r iat e p r oced ur e code .-51 M u lt ip le p r oced ur es : Wh e n mu lt ip le s ur gica l p r oced ur es /se r vices (oth e rthan eva luat ion an d mana ge m e nt ) ar e pe r form ed at th e s am e sess ion , byth e s am e p r ovide r , th e p r imar y p r oced ur e or se r vice is r ep ort ed a s lis t ed .T h e a dd it iona l p r oced ur es s ha ll be ide nt ifie d by a ppe n d in g th e m od ifie r -51 . N ot e : T h is m od ifie r s ha ll n ot be a ppe n ded t o des ignat ed a dd -oncodes lis t ed in C P T .-52 Red u ced se r vices : Und e r ce rta in cir cum s tan ces , a p r oced ur e is p art ia llyr ed u ced or elim inat ed at th e p ra ct it ion e r ’s d is cr e t ion . Und e r th esecir cum s tan ces , th e se r vice p r ovided s ha ll be ide nt ifie d by it s u s ua lp r oced ur e code an d th e a dd it ion of th e m od ifie r -52 .-53 Dis cont inu ed p r oced ur e: I f th e p h ys ician ele ct s t o t e rm inat e a s ur gica lor d ia gn os t ic p r oced ur e be cau se of ext e nuat in g cir cum s tan ces orcir cum s tan ces that thr e at e n th e well bei n g of th e p at ie nt , th e de cis ion t ot e rm inat e or d is cont inu e th e p r oced ur e s ha ll be r ep ort ed by a dd in gm od ifie r -53 t o th e code of th e d is cont inu ed p r oced ur e . Mod ifie r -53 s ha lln ot be u sed t o r ep ort th e ele ct ive can cellat ion of a p r oced ur e be for e th ep at ie nt ’s an es th esi a in d u ct ion or s ur gica l p r ep arat ion in th e ope rat in gs u it e , or b oth .-54 S ur gica l car e on ly: Wh e n 1 p ra ct it ion e r pe r form s a s ur gica l p r oced ur ean d an oth e r p r ovides p r e ope rat ive or p os t ope rat ive mana ge m e nt orb oth , s ur gica l se r vices s ha ll be ide nt ifie d by a dd in g th e m od ifie r -54 t oth e p r oced ur e code .-55 P os t ope rat ive mana ge m e nt on ly: Wh e n 1 p ra ct it ion e r pe r form s th ep os t ope rat ive mana ge m e nt an d an oth e r p ra ct it ion e r pe r form s th eTable 10904 Modifier Codes
s ur gica l p r oced ur e , th e p os t ope rat ive com p on e nt s ha ll be ide nt ifie d bya dd in g th e m od ifie r -55 t o th e u s ua l p r oced ur e code .-56 Pr e ope rat ive mana ge m e nt on ly: Wh e n 1 p ra ct it ion e r pe r form s th ep r e ope rat ive car e an d eva luat ion an d an oth e r p ra ct it ion e r pe r form s th es ur gica l p r oced ur e , th e p r e ope rat ive com p on e nt s ha ll be ide nt ifie d bya dd in g m od ifie r -56 t o th e u s ua l p r oced ur e code .-57 De cis ion for s ur ge r y : An eva luat ion an d mana ge m e nt se r vice thatr es u lt s in th e in it ia l de cis ion t o pe r form th e s ur ge r y ma y be ide nt ifie d bya dd in g m od ifie r -57 t o th e a pp r op r iat e level of eva luat ion an dmana ge m e nt se r vice .-58 S ta ge d or r elat ed p r oced ur e or se r vice by th e s am e p h ys ician d ur in g th ep os t ope rat ive pe r iod : I f th e p h ys ician n eeds t o in d icat e that th epe r forman ce of a p r oced ur e or se r vice d ur in g th e p os t ope rat ive pe r iodw a s p lann ed p r ospe ct ively at th e t im e of th e or igi na l p r oced ur e , w a sm or e ext e n s ive than th e or igi na l p r oced ur e , or w a s for th e ra p y followin ga d ia gn os t ic s ur gica l p r oced ur e , th e cir cum s tan ce s ha ll be r ep ort ed bya dd in g m od ifie r -58 t o th e s ta ge d or r elat ed p r oced ur e .-59 Dis t in ct p r oced ura l se r vice: I f th e p h ys ician n eeds t o in d icat e that ap r oced ur e or se r vice w a s d is t in ct or in depe n de nt fr om th e oth e r se r vicespe r form ed on th e s am e d a y, m od ifie r -59 s ha ll be u sed t o ide nt ify th ep r oced ur e or se r vice , or b oth that ar e n ot n orma lly r ep ort ed t oge th e r , b utar e a pp r op r iat e un de r th e cir cum s tan ces .-62 Tw o s ur ge on s : Wh e n 2 s ur ge on s w ork t oge th e r a s p r imar y s ur ge on spe r form in g d is t in ct p art s of a s in gle r ep orta ble p r oced ur e , e a ch s ur ge ons h ou ld r ep ort h is d is t in ct ope rat ive w ork by a dd in g th e m od ifie r -62 t o th es in gle de fin it ive p r oced ur e code . Ea ch s ur ge on s h ou ld r ep ort th e co-s ur ge r y on ce u s in g th e s am e p r oced ur e code . I f a dd it iona l p r oced ur e orp r oced ur es ar e pe r form ed d ur in g th e s am e s ur gica l sess ion , sep arat ecodes ma y be r ep ort ed with out th e m od ifie r -62 . N ot e: I f a co-s ur ge ona ct s a s an a ss is tant in th e pe r forman ce of a dd it iona l p r oced ur es d ur in gth e s am e s ur gica l sess ion , th ose se r vices ma y be r ep ort ed u s in g sep arat ep r oced ur es with m od ifie r -80 or -81 a s a pp r op r iat e.-66 S ur gica l t e am : Und e r s om e cir cum s tan ces , h igh ly com p lex p r oced ur esr eq u ir e th e con com itant se r vices of se ve ra l p h ys ician s , oft e n of d iffe r e ntspe cia lt ie s , an d oth e r h igh ly sk ille d , spe cia lly tra in ed pe r s onn el w h out ilize var iou s t ypes of com p lex eq u ip m e nt ar e carr ie d out un de r th e“s ur gica l t e am ” con cep t . T h is cir cum s tan ce s ha ll be ide nt ifie d by e a chp art icip at in g p h ys ician by a dd in g m od ifie r -66 t o th e b a s ic p r oced ur ecode num be r u sed for r ep ort in g se r vices .-76 Repe at p r oced ur e by s am e p ra ct it ion e r : Wh e n th e p ra ct it ion e r n eeds t oin d icat e that a p r oced ur e or se r vice w a s r epe at ed s u bseq u e nt t o th eor igi na l se r vice , th e p ra ct it ion e r s ha ll r ep ort th e r epe at p r oced ur e orse r vice by a dd in g m od ifie r -76 t o th e p r oced ur e code .Table 10904 Modifier Codes
-77 Repe at p r oced ur e by an oth e r p ra ct it ion e r : T h e p ra ct it ion e r ma y n eed t oin d icat e that a b a s ic p r oced ur e pe r form ed by an oth e r p ra ct it ion e r ha d t obe r epe at ed . T h is s ha ll be r ep ort ed by a dd in g m od ifie r -77 t o th er epe at ed se r vice.-78 Re turn t o th e ope rat in g r oom for a r elat ed p r oced ur e d ur in g th ep os t ope rat ive pe r iod : Wh e n th e p h ys ician n eeds t o in d icat e that an oth e rp r oced ur e w a s pe r form ed d ur in g th e p os t ope rat ive pe r iod of th e in it ia lp r oced ur e an d th e s u bseq u e nt p r oced ur e is r elat ed t o th e fir s t an dr eq u ir es th e u se of th e ope rat in g r oom , th e s u bseq u e nt p r oced ur e s ha llbe r ep ort ed by a dd in g m od ifie r -78 t o th e r elat ed p r oced ur e code .-79 Unr elat ed p r oced ur e or se r vice by th e s am e p h ys ician d ur in g th ep os t ope rat ive pe r iod : Wh e n th e p h ys ician n eeds t o in d icat e that th epe r forman ce of a p r oced ur e or se r vice d ur in g th e p os t ope rat ive pe r iodw a s unr elat ed t o th e or igi na l p r oced ur e , m od ifie r -79 s ha ll be u sed t odes cr ibe th e cir cum s tan ce.-80 Ass is tant s ur ge on : Wh e n s ur gica l a ss is tant se r vices ar e p r ovided by ad oct or of de nta l s ur ge r y, d oct or of m edi cin e , d oct or of os t e op ath y, or ad oct or of p od iatr y, m od ifie r -80 s ha ll be a dded t o th e u s ua l p r oced ur ecode or codes t o ide nt ify th e se r vice .-81 Min imum a ss is tant s ur ge on : Wh e n s ur gica l a ss is tant se r vices ar ep r ovided by a p h ys ician ’s a ss is tant or nur se p ra ct it ion e r , m od ifie r -81s ha ll follow th e a pp r op r iat e p r oced ur e code or codes t o ide nt ify th ese r vice.-99 M u lt ip le m od ifie r s : Wh e n 2 or m or e m od ifie r s ar e n e cess ar y t o de lin e at ea se r vice , m od ifie r -99 s ha ll follow th e b a s ic p r oced ur e , an d oth e ra pp lica ble m od ifie r s s ha ll be lis t ed a s a p art of th e des cr ip t ion of th ese r vice.-
S u pe r vis ion of an es th esi a se r vices :When an an esth esiologist SA supervises , OR PROVIDES MEDIC AL DIR ECTIO N TO, a cert ified registered nur se an esth etist or an esth esiology reside nt, m od ifie r -S As ha ll follow th e a pp r op r iat e an es th esi a p r oced ur e code.-
An es th esi ologis t se r vices :When an an esth esiologist bills for services AA per form ed by th e an esth esiologist,m od ifie r -AA s ha ll follow th ea pp r op r iat e an es th esi a p r oced ur e code.-
Lice n sed ps ych ologis t :When a licensed psychologist bills a diagnostic AH service or a th era peut ic service, or both, m od ifie r -AH s ha ll follow th ea pp r op r iat e p r oced ur e code.-AJ
Ce rt ifie d s ocia l work e r :When a cert ified socia l work er bills a THE RAPEU TIC service,m od ifie r -AJ s ha ll follow th e a pp r op r iat eTable 10904 Modifier Codes
p r oced ur e code.-
Nurs e with a spe cia lt y ce rt ificat ion :When a nur sewithWHO HAS a AK spe cialty cert ificat ion, as defined in th ese ru les, TREATS AN IN J URED WORK ER AND bills a service oth er than assistant at sur gery,m od ifie r -AK s ha ll follow th e a pp r op r iat e p r oced ur e code.-
Lim it ed lice n se ps ych ologis t : W h e n aA limited license psychologist AL billsING a diagnostic service or a th era peut ic service,or both , m od ifie r -AL s ha ll follow th e a pp r op r iat e p r oced ur e code.-
Ph ys ician ’s a ss is tant :When a physician ’s assistantbills, TREATS AN AU IN J URED WORK ER FOR A MEDIC ALaservice oth er than assistant at sur gery,m od ifie r -AU s ha ll follow th e a pp r op r iat e p r oced ur e code.-
Lim it ed lice n sed coun se lor :When a limited licensed coun selor bills FOR CS A THE RAPEU TICaservice,m od ifie r -CS s ha ll follow th e a pp r op r iat ep r oced ur e code.-
Lice n sed p r ofessi ona l coun se lor :When a licensed pr ofessi ona l coun selor LC perform s a THE RAPEU TIC service,m od ifie r -LC s ha ll follow th ea pp r op r iat e p r oced ur e code.-
Lice n sed marr ia ge an d fam ily th e ra p is t :When a licensed marr iage an d MF fam ily th era pist perform s a THE RAPEU TIC service,m od ifie r -M F s ha llfollow th e a pp r op r iat e p r oced ur e code.-
Lim it ed lice n sed marr ia ge an d fam ily th e ra p is t :When a limited licensed ML marr iage an d fam ily th era pist per form s a service,m od ifie r -ML s ha llfollow th e a pp r op r iat e p r oced ur e code.-
Pat ie nt -contr olle d ana lge s ia :When PATIEN T-CONTROLL ED P C ANALGESIAa se r viceis provided by a physician who owns th e pat ient - contr olled ana lgesia equipment, m od ifie r -P C s ha ll follow p r oced ur e code01999.-
Te chn ica l com p on e nt of a se r vice , e .g., WHEN BILLI NG FOR THE TC techn ical com ponent of a ra diology service.-
Ce rt ifie d r egis t e r ed nur se an es th e t is t :When a cert ified registered nur se QX an esth etist per form s a service un der th e MEDIC AL direction of an an esth esiologist,m od ifie r -QX s ha ll follow th e a pp r op r iat e an es th esi ap r oced ur e code.-
Ce rt ifie d r egis t e r ed nur se an es th e t is t b a se un it s :When a cert ified QZ regis tered nur se an esth et ist perform s ANES THE SIA SERVICES WITHOUT MEDIC AL DIR ECTIO N,an d bills ba se un it s , m od ifie r -QZs ha ll follow th e a pp r op r iat e an es th esi a p r oced ur e code.R 418 .10909 BILLI NG FOR HOME HE ALTH SER VICES .
RULE 909 . (1) SERVICES PROVIDED BY A HOME HE ALTH AGEN CY ARE CONSI DERED ANCILL ARY SERVICES REQUI RING A PH YSICI AN’S PRESCRI PTIO N CERTI FYING MEDIC AL NE CESSIT Y. A COPY OF THE PRE SCRI PTIO N SHALL BE ATTACHE D TO THE BILL .
(2) A HOME HE ALTH AGEN CY SHALL SUBMIT CHARGES TO THE WORK ERS’ COMPEN SATIO N CARRI ER USIN G THE UB-92 CLAIM FORM.
(3) A HOME HE ALTH AGEN CY SHALL USE PROCEDURE CODES FROM “HCPCS, MEDIC ARE’S NATIO NAL LEVEL II COD ES” ADOPTED BY REFE REN CE IN R 418 .10107 TO IDEN TIFY SERVICES PROVIDED.
(4) A HOME HE ALTH AGEN CY MAY NOT BILL FOR THE SERVICES OF A SOCI AL WORK ER UN LESS THE CERTI FIED SOCI AL WORK ER IS PROVIDING MEDIC ALLY NE CESSARY THE RAPEU TIC COUNSE LING.
(5) A HOME HE ALTH AGEN CY MAY BILL SU PP LIES WITH 99070 , THE UN LIST ED CPT COD E FOR MISC ELLANE OUS SU PP LIES, OR THE APP ROPRIATE SU PP LY CODE FROM “MEDIC ARE’S NATIO NAL LEVEL II CODES HCPCS” AS ADOPTED BY REFE REN CE IN R 418 .10107 .
(6) WHEN A PROCEDURE CODE IS DESCRIB ED BY “HCPCS, MEDIC ARE’S LEVEL II ” AS PE R DIEM, THE “BY REP ORT” SERVICE IS REIMBURS ED PE R VISIT . WHEN “HCPCS, MEDIC ARE’S LEVEL II ” DESCRIB ES A SERVICE AS TIM E-BASED THE SERVICE IS “BY REP ORT,” AND THE PROCEDURE IS REIMBURS ED ACCORDI NG TO THE TIM E PROVIDED.
R 418 .10912 Bi lli ng for presc ri ption med icatio ns .
RULE 912 . (1) PRESCRI PTIO N DRUGS MAY BE DIS PEN SED TO AN IN J URED WORK ER BY EITHE R AN OUTPATIEN T PH ARMACY OR A HE ALTH CARE
ORGANIZATIO N AS DEF IN ED IN THE SE RULES. These ru les sha ll apply to THE PH ARMACY DIS PEN SING THE PRESCRI PTIO N DRUGS TO AN IN J URED WORK ER
a p r ovide r of p r es cr ip t ion d ru gsonly after th e pharma cy ha s eith er writt en or ora l con firmat ion from th e carr ier that th e prescriptions or supplies ar e cover ed by work ers’ com pensat ion insuran ce.(2) A bill or receipt for a prescription dru g from an out pat ient pharma cy, pra ct it ioner, or health car e organ izat ion sha ll BE SUBMITT ED TO THE CARRI ER AND SHALL INCLUD E THE NAME, ADDRESS, AND SOCI AL SECURIT Y NU MBER OF THE IN J URED WORK ER.
s ha ll in clu de a ll of th e followin g in format ionAN OUTPATIEN T PH ARMACY SHALL BILL THE SERVICE USIN G THE UNI VERSAL PH ARMACY CLAIM FORM OR AN IN VOIC E AND SHALL INCLUD E THE NATIO NAL ASSOCI ATIO N BOARD OF PH ARMACY IDEN TIFICATIO N NU MBER AND THE SERIAL NU MBER OF THE PRESCRI PTIO N DRUG.(3) A HE ALTH CARE ORGANI ZATIO N OR PH YSICI AN OFF ICE DIS PEN SING THE PRESCRI PTIO N DRUG SHALL BILL THE SERVICE ON THE HCFA 1500 CLAIM FORM. PROCEDURE CODE 99070 SHALL BE USE D TO CODE THE SERVICE AND THE NATIO NAL DRUG CODE SHALL BE USE D TO DESCRIB E THE DRUG.
(4) IF AN IN J URED WORK ER HAS PAID FOR A PRESCRI PTIO N DRUG FOR A COVERED WORK ILLN ESS, THEN THE WORK ER MAY SEN D A RECEIPT SHOWING PAYMEN T ALONG WITH THE DRUG IN FORMATIO N TO THE CARRI ER FOR RE IMBURS E MEN T.
(5) AN OUTPATIEN T PH ARMACY OR HE ALTH CARE ORGANI ZATIO N SHALL
include a ll of th e following informat ion WHEN SUBMITTING A BILL FOR A PRESCRI PTIO N DRUG TO THE CARRI ER:
(a) The bran d or chemical nam e of th e dru g dispe nsed .
(b) The manu factur er or supplier’s nam e AND THE NDC, OR NATIO NAL DRUG CODE FROM THE “RED BOOK ” AS ADOPTED BY REFE REN CE IN R 418 .10107 .
(c) The dosage, str ength , an d quant ity dispe nsed
of th e d ru g.(d)
) T h e nam e an d a dd r ess of th e p harma cy that d ispe n sed th e d ru g.(
gE) Thenam e of th ePH YSICI AN prescriberINGofth e dru g.(h ) T h e nam e , a dd r ess , an d s ocia l se cur it y num be r of th e p at ie nt .(i) T h e p r ice for w h ich th e d ru g w a s s old t o th e p ur chaser.(j)T h e nat iona l d ru g code num be r.(k)) T h e nat iona l a ss ociat ion b oar d of p harma cy ide nt ificat ion num be r .(3 ) I f a p ra ct it ion e r or h e a lth car e or gan izat ion oth e r than an in p at ie nt h osp ita l d ispe n ses ap r es cr ip t ion d ru g, th e n p r oced ur e code 99070 s ha ll be u sed t o code th e p r oced ur e an d th enat iona l d ru g code num be r fr om th e “Red B ook ” s ha ll be u sed t o ide nt ify th e d ru g(6
4)I f aA pra ct it ioner or a health car e organ izat ion, oth er than an inpat ient hospita l,d ispe n ses a d ru g, th e n th e p ra ct it ion e rsha ll bill WC700 to describe th e dispe nse fee FOR each prescription dru g. A PROVIDER WILL ONLY BE REIMBURS ED FORN ot m or ethan1 dispe nse feeof $4 .00 s ha ll be p a id pe rFOR each prescription dru g in a 10-day period. A dispe nse fee sha ll not be billed with “OTC ”’s, over-th e-count er dru gs.P ART 9. BILLI NG
SUB P ART A. P RACTITIO NER BILLI NG
Rule 916 . (1) This ru le applies to th e pra ct it ioner com ponent of minor pr oced ur es that can safely be per form ed in a sett ing oth er than an out pat ient hospita l. If a pra ct it ioner or health car e organ izat ion submits a bill for a pr oced ur e code listed in ta ble 10916 in th e out pat ient hospita l sett ing, th en modifier code -26 sha ll be added to th e pr oced ur e code an d th e carr ier sha ll pay THE MAXIMUM ALLOW ABLE FEE LIST ED IN THE MANU AL FOR THE TECHN ICAL PORTIO N OF THE PROCEDURE, OR IF THE TECHN ICAL PORTIO N IS NOT LIST ED THEN THE CARRI ER SHALL PAY 40 % of th e ma ximum
allowable fee for th e pr oced ur e.
A ra d iologis t s ha ll be r eim b ur sed by th e ma ximuma llow a ble p a ym e nt for th e p r ofessi ona l com p on e nt of th e p r oced ur e , ide nt ifie d by m od ifie r -26 .(2) This ru le sha ll not apply to ANY OF th e followin g instan ces:
(a) Dur ing an inpat ient , obse rvat ion sta y, or services appropriat ely per form ed in th e emergency r oom dep artm ent .
(b) For pr oced ur es per form ed dur ing an out pat ient sur gery.
(c) If pr oced ur es from
Tta ble 10916 ar e per form ed dur ing th e cour se of an out pat ient sett ing in con jun ct ion with a pr oced ur e that is appropriat ely per form ed in th e out pat ient sett ing; for exam ple, a ra diology pr oced ur e with a myelogram or out pat ient sur gery.(3) This ru le sha ll not apply if th e pr oced ur e is per form ed by an emergency r oom physician grant ed privilege s by th e hospita l to pra ct ice in th e emergency r oom .
(4) Table 10916 reads as follows :
TABLE 10916
10060
20665 -20670
30901
67700
92230 -9249910120
23065
40800
67715 -67805
93740
10140
23330
40804
67810 -67825
94010 -95065
10160
24065
40820
67938
95115 -95199
11000
24200
41000 -41005
69000
95180
11040
25065
41800 -41805
69020
95860 -95904
11100 -11101
26010
42300 , 42310
70030 -70360
95930 -95937
11720 -11750
27040
45300
70450 -71030
98925 -98943
11900 -11901
27086
45330
71100 -72220
99195
12001 -12004
27323
46050
73000 -74420
99201 -992
41515860
27613
50398
74400 -74420
99241 -99245
16000
28001
51000
78300 -78699
9
90801 -9981516020 -16030
28190
51700 -51710
90901 -90911
20500
3000 -30100
53600 -53661
92002 -92014
20520
30200 -30210
53670 -53675
92230 -92504
20550 -20610
30300
65205 -65222
92531 -92599
R 418 .10918 Bi lli ng procedu re codes tha t on ly have a profess io na l component . Resc inded
R u le 918 . Pr oced ur e codes in th e followin g ta ble ha ve on ly a p r ofessi ona l com p on e nt an ds ha ll on ly be billed by a p ra ct it ion e r or a h e a lth car e or gan izat ion .T ABL E 1091820501273705039488300 -88399211162764850684930102335031708 -3171550690930182422036000 -3621851600 -516109304525246366006228493204270933879062290 -62291P ART 9. BILLI NG
SUB P ART B. FACILIT Y BILLI NG
R 418 .10923 Hospital billi ng for practitione r se rvices .
Rule 923 . (1) A hospita l billing for pra ct it ioner services, including a cert ified registered nur se an esth etist, a physician , a nur se who ha s a specialty cert ificat ion, an d a physician ’s assistant sha ll submit bills on a HCFA 1500 form an d th e hospita l sha ll use th e appropriat e pr oced ur e codes adopted by th ese ru les.
(a) A hospita l or hospita l-system owned office pra ct ice sha ll bill all office services as pra ct it ioner services on a HCFA 1500 form using site of service 3 or 11.
(b) A hospita l or hospita l-system owned industr ial or occu pat iona l clinic sha ll bill all clinic services as pra ct it ioner services on a HCFA 1500 using site of service 3 or 11. Radiology an d laborat ory services ma y be billed as facility services on th e UB-92.
(2)) A p r oced ur e code lis t ed in R 418 .10918 des cr ibe s p r ofessi ona l se r vices billed on ly by ap ra ct it ion e r . I f billi n g p r oced ur es lis t ed in R 418 .10918 , th e n th e h osp ita l s ha ll on ly bill ona H C F A 1500 form .(a)) A p r oced ur e conta in ed on ta ble 10924 can s a fely be pe r form ed in se tt in gs oth e r than anin p at ie nt h osp ita l. I f billed by th e h osp ita l or p ra ct it ion e r , th e n th e se r vice s ha ll be billedon a H C F A 1500 form with m od ifie r -26 an d th e carr ie r s ha ll r eim b ur se th e se r vice at 40 %of th e ma ximum a llow a ble p a ym e nt , or 40 % of th e p ra ct it ion e r ’s u s ua l an d cu s t omar ychar ge, w h ich eve r is le ss .(
32) A HOSPITAL BILLI NG FOR A ra diologist’S SERVICES sha ll billon lyth e pr ofessi ona l com ponent ofaTHE ra diologicY procedur e ON THE HCFA 1500 CLAIM F ORM.T h e p r ofessi ona l com p on e ntAND sha llbe ide nt ifie d byplacEi n gmodifiercode-26 after th e appropriat e ra diologicY procedur e code TO IDEN TIFY THE PROFE SSION AL COM PONEN T OF THE SERVICE.(
43) A HOSPITAL BILLI NG FOR THE PROFE SSION AL COMPONEN T OF A path ologistY SERVICE sha ll bill THE SERVICE ON A HCFA 1500 CLAIM FORM ANDon ly th e p r ofessi ona l com p on e nt of a p ath ology p r oced ur e .ADD MODI FIER –26T h ep r ofessi ona l com p on e nt , s ha ll be ide nt ifie d by p la cin g m od ifie r code -26 a ft e r th ea pp r op r iat e p r oced ur e code .(
54) A HOSPITAL BILLI NG FOR A cert ified registered nur se an esth etist sha ll bill only t ime un it s of an an esth esiology procedur e AND USE MODI FIER –QX WITH THE APP ROPRIATE ANES THE SIA CODE, except in th e abse nce of medical direction from a supervising an esth esiologist.P ART 10 . RE IMBURSE MEN T
SUB P ART A. P RACTITIO NER RE IMBURSE MEN T
R 418 .101002 Conve rsion facto rs for med ical , su rgica l, and radio logy procedu re codes .
Rule 1002 . (1) The bur eau sha ll determ ine th e con version factors for medical, sur gical, an d ra diology pr oced ur es. The con version factor sha ll be used by th e bur eau for determ ining th e ma ximum a llowable payment for medical, sur gical, an d ra diology pr oced ur es. The ma ximum a llowable payment sha ll be determ ined by mu lt iplying th e appropriat e con version factor t imes th e relat ive value un it assigned to a pr oced ur e. The relat ive value un it s ar e listed for th e medicine, sur gical, an d ra diology pr oced ur e codes in a manua l sep arat e from th ese ru les. The manua l sha ll be published annua lly by th e bur eau using codes adopted from “Curr ent Pr oced ura l Term inology” as referenced in R 418 .10107 (a). The Bur eau sha ll determ ine th e relat ive values by using informat ion foun d in th e “RBRVS: Fee Schedule” as adopted by reference in R 418 .10107 (c).
(2) The
thr ee3 con version factors for medicine, ra diology, an d sur gical pr oced ur es sha ll be pha sed int oon e1 con version factor. The con version factors ar e listed in th e followin g ta ble:Table 1002
Type of Service
Year 2000
Year 2001
Year 2002
Medi cine pr oced ur e codes , 90281 -99199
$41 .83
$44 .42
$47 .01
Radiology procedur e codes , 70010 -79999
$46 .
456$46 .74
$47 .01
Sur gery pr oced ur e codes , 10040 -69979
$48 .62
$47 .82
$47 .01
(a) The con version factors for year 2000 sha ll be effect ive for dat es of service occurr ing on or after th e effect ive dat e of th ese ru les.
(b) The con version factors for th e year 2001 sha ll be effect ive for dat es of service occurr ing on or after J anuar y 1, 2001 .
(c) The single con version factor of $47 .01 sha ll be effect ive for all services occurr ing on or after J anuar y 1, 2002 .
(3) The 1999 Relat ive Values adopted from “RBRVS 1999 Fee Schedule: A Plain En glish Guide” AS ADOPTED BY REFE REN CE IN R 418 .10107 , sha ll be used for determ ining th e ma ximum a llowable payment dur ing th e pha se-in period of con vert ing to
on e1 conversion factor.(a) If new procedur e codes ar e added int o “Curr ent Pr ocedura l Term inology, CPT” as adopted by reference in R 418 .10107 , th en th e relat ive value AND GLOB AL PE RIOD listed in th e most recent edition of th e
“RBR VS F ee S ch ed u le : A p la in En gli s hG u ide ”“ME DIC ARE RBRVS Fee Schedule: A PH YSICI ANS’ Guide” as adopted by reference in R 418 .10107 sha ll be used by th e bur eau to determ ine th e ma ximum a llowable payment for new procedur e codes not listed in th e “RBRVS 1999 Fee Schedule: A Plain En glish Guide.”R 418 .101005 RE IMBURSE MEN T FOR HOME HE ALTH SER VICES .
RULE 1005 . (1) HOME HE ALTH SERVICES ARE REIMBURS ED “BY REP ORT”, REQUI RING SUBMISSION OF A REP ORT WITH THE CHARGES ON THE UB-92 CLAIM FORM. THE CARRI ER SHALL REIMBURS E THE HOME HE ALTH AGEN CY ACCORDI NG TO EACH “BY REP ORT” PROCEDURE LIST ED ON THE UB-92 , BILL ED WITH THE APP ROPRIATE HCPCS COD E IN ACCORD WITH R 418 .10909 .
(2) HOME HE ALTH SERVICES SHALL BE REIMBURS ED BY THE CARRI ER AT EITHE R THE PROVIDER’S USU AL AND CUS TOMARY CHARGE AS DEF IN ED BY THE SE RULES OR REASON ABLE AMOUN T, WHICHE VER IS LESS.
(3) SERVICES LIST ED IN “HCPCS, MEDIC ARE LEVEL II COD ES” AS ADOPTED BY REFE REN CE IN R 418 .10107 AS PE R DIEM SHALL BE REIMBURS ED PE R DIEM OR PE R VISIT IN ACCORD WITH THE DESCRI PTIO N OF THE COD E. THE PE R DIE M VISIT SHALL BE EITHE R AT THE PROVIDER’S USU AL AND CUS TOMARY CHARGE OR REASON ABLE AMOUN T, WHICHE VER IS LESS.
(4) WHEN A HOME HE ALTH AGEN CY BILLS FOR SU PP LIES ON THE UB-92 , THE SU PP LIE S SHALL BE RE IMBURS ED AT AWP, AVERAGE WHOLE SALE PRIC E PLUS NOT MOR E THAN A 50 % MARKUP ABOVE AVERAGE WHOLESALE PRIC E.
