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ORR # 2001-041
DEPARTMENT OF CONSUMER AND INDUSTRY SERVICES BUREAU OF WORKERS' DISABILITY COMPENSATION WORKER'S COMPENSATION HEALTH CARE SERVICES
Filed with the Secretary of State on January 3, 2002.
These rules take effect 7 days after filing with the Secretary of State
(By authority conferred on the bureau of worker's disability compensation by sections 205 and 315 of 1969 PA 317, section 33 of 1969 PA 306, Executive Reorganization Order No. 1982-2, Executive Reorganization
Order No. 1986-3, and Executive Reorganization Order No. 1990-1, MCL 418.205, 418.315, 24.233,
18.24, 418.1, and 418.2
R 418.10107, R 418.10115, 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, and R 418.101002, of the Michigan Administrative Code are amended, R 418.10909 and R 418 101005 are added to the code, and R 418.10405, R 418.10406, R 418.10407, R 418.10411, R 418.10415, R 418.10501, R 418.10502, R 418.10503, and
R 418.10918 of the Michigan Administrative Code are rescinded to read as follows:
PART 1. GENERAL PROVISIONS
R 418.10107 Source documents.
Rule 107. The following documents are adopted by reference in these rules and are available for inspection at, or purchase from, the bureau of workers' disability compensation, health care services division, P.O. Box 30016, Lansing, Michigan 48909, at the costs listed or from the organizations listed:
(a) "Physicians’ Current Procedural Terminology (CPT®) 2002," standard edition, copyright October 2001,
published by the American Medical Association, 515 N State Street, Chicago, IL 60610, order
# OP054102BLC, 1-800-621-8335. The publication may be purchased at a cost of $49.95, plus $6.95 for shipping and handling as of the time of adoption of these rules. Permission to use this publication is on file in the bureau.
(b) "Medicare's National Level II Codes, HCPCS, 2002," Millennium Edition, copyright November 2001, published by the American Medical Association, P.O. Box 7046, 515 N State Street, Chicago, IL 60610, order # OP096102BLC customer service 1-800-621-8335. The publication may be purchased at a cost of
$49.95, plus $6.95 for shipping and handling as of the time of adoption of these rules.
(c) "RBRVS, Fee Schedule: A Plain English Guide," 1999 edition, published by United Communications Group, 11300 Rockville Pike, Suite 1100, Rockville, MD 20852-3030. Customer service 1-301-287-2700. The handbook may be purchased at a cost of $49.95 as of the time of adoption of these rules.
(d)“Medicare RBRVS 2002: The Physicians’ Guide,” published by The American Medical Association, 515 North State Street, Chicago IL, 60610, order #OPO59602BLC, 1-800-621-8335. The publication may be purchased at a cost of $74.95,plus $8.95 shipping and handling as of the time of adoption of these rules.
(e) "International Classification of Diseases, ICD-9-CM 2002" Millennium Edition, copyright 2001, American Medical Association, P.O. Box 7046, 515 N State Street, Chicago, IL 60610, order #OP068102BLC, 1-800-621-8335. The publication may be purchased at a cost of $59.95, plus $8.95 shipping and handling as of the time of adoption of these rules.
(f) "2002 Drug Topics Red Book," published by Medical Economics Company Inc., Five Paragon Drive, Montvale, NJ 07645-1742, 1-800-678-5689. The publication may be purchased at a cost of $64.95, plus
$7.95 for shipping and handling as of the time of adoption of these rules.
(g) "Michigan Uniform Billing Manual," developed in cooperation with the American Hospital Association's National Uniform Billing Committee, published by Michigan Health and Hospital Association, 6215 West St. Joseph Highway, Lansing, MI 48917, 517-886-8366. As of the time of adoption of these rules, the cost of the publication is $135.00, plus 6% sales tax.
R 418.10115 Responsibilities of insured employer or self-insurer.
Rule 115.(1) An insured employer shall do all of the following:
(a) Promptly file form 100, employer’s basic report of injury, to report an injury that results in 7 or more days of disability, specific loss, or death, with the bureau and its insurer.
(b) Promptly notify its insurer of the cases that do not result in 7 or more days of disability, specific loss, or death.
(c) Promptly inform the provider of the name and address of its insurer or the designated agent of the insurer to whom health care bills should be sent.
(d) If an insured employer receives a bill, then the insured employer shall promptly transmit the provider’s bill and documentation to the insurer or the designated agent of the insurer regarding a related injury or illness.
(2) For the purposes of this rule, a self-insurer shall promptly report all employee work-related injuries to their designated agent, unless they are self-administered.
(a) Unless self-administered, a self-insurer receiving a bill for a medical service shall forward the bill to their designated agent for processing and shall inform the medical provider of the address where future bills shall be sent.
R 418.10116 Provider responsibilities.
Rule 116. (1) A provider shall do both of the following:
(a) Promptly bill the carrier or the carrier’s designated agent after the date of service.
(b) Submit the bill for the medical services provided to treat an injured worker on the proper claim form, to the workers’ compensation carrier or the carrier’s designated agent and shall attach the documentation required in part 9 of these rules.
(c) If a carrier requests the provider to send duplicated copies of the documentation required in part 9 or additional medical records not required by these rules, then the carrier shall reimburse the provider for the copying charges in accord with R 418.10118.
(2) If the provider has not received payment within 30 days of submitting a bill, then the provider shall resubmit the bill to the carrier and add a 3% late fee.
R 418.10117 Carrier responsibilities.
Rule 117. (1) The carrier or its designated agent shall assure that a billing form is completed properly before making payment.
(2) A carrier may designate a third party to receive provider bills on its behalf. If a carrier instructs the provider to send the medical bills directly to the third party, then the 30-day limit of this rule begins when the third party receives the bill. The carrier is responsible for forwarding bills and medical documentation when there is a third party reviewing medical bills for the carrier.
(3) A carrier or designated agent shall make payment of an unadjusted and properly submitted bill within 30 days of receipt of a properly submitted bill or shall add a self-assessed 3% late penalty to the maximum allowable payment as required by these rules.
(4) A carrier or designated agent shall make payment of an adjusted bill or portion of an adjusted bill within 30 days of receipt of the properly submitted bill. If a carrier or designated agent rejects a bill in its entirety, then the carrier or designated agent shall notify the provider of the rejection within 30 days after receipt of a properly submitted bill.
R 418.10202 Evaluation and management services.
Rule 202. (1) Procedure code 97010 performed in conjunction with an evaluation and management office visit shall not be reimbursed as a separate procedure.
(2) Minor medical and surgical supplies routinely used by the practitioner or health care organization in the office visit shall not be billed separately.
(3) Supplies, or other services, over and above those usually incidental to an office visit or other outpatient visit for the evaluation and management of a patient shall be billed separately under procedure code 99070.
(4) If an office visit is performed outside of the provider’s normal business hours, the provider may bill the add on procedure codes describing an office visit performed after hours or on Sundays or holidays. A provider may bill add on procedure code 99050 in addition to the evaluation and management service, if a service is rendered between the hours of 6:00 p.m. and 7:00 a.m., Monday through Saturday. A provider may bill add on procedure code 99054 if a service is rendered on Sundays or holidays until 7:00 a.m. of the following regular working day.
(5) A procedure that is normally part of an examination or evaluation shall not be billed independently.
(a) Range of motion shall not be reimbursed as a separate procedure in addition to the evaluation and management service unless the procedure is medically necessary and appropriate for the injured worker’s condition and diagnosis.
(6) The maximum allowable payment for the evaluation and management service shall be determined by multiplying the relative value unit, RVU, assigned to the procedure code, times the conversion factor listed in the reimbursement section of these rules.
(7) The level of an office visit or other outpatient visit for the evaluation and management of a patient is not guaranteed and may change from session to session. The level of service shall be consistent with the type of presenting complaint and supported by documentation in the record.
(8) Procedure codes 99455 and 99456 describing work-related or medical disability evaluation services shall not be used to describe an evaluation and management service for treating a work-related injury or illness. Procedure codes 99201-99350 shall be used to describe the practitioner’s medical treatment of an injured worker.
(9) The carrier shall not reimburse the provider for procedure codes 90782-90799, administration of therapeutic injections, if billed in conjunction with an evaluation and management service. The medication
administered in the therapeutic injection shall be billed using procedure code 99070 and shall be identified with the national drug code number. The provider shall be reimbursed at the average wholesale price of the drug. If the provider does not bill an evaluation and management service then the appropriate procedure code describing the administration of the drug may be billed. The administered drug is billed additionally and is payable at the average wholesale price of the drug.
(10) The provider may bill immunization procedure codes in addition to the evaluation and management procedure code. If the provider bills an immunization, then the vaccine is described with procedure codes 90476-90748, and the administration of the vaccine is described with procedure code 90471 or 90472. The carrier shall reimburse the vaccine at the average wholesale price of the vaccine plus the cost of administration billed with procedure codes 90471 or 90472. Procedure code 90471 is reimbursed at $5.00 and procedure code 90472 is reimbursed at $7.50.
R 418.10205 Consultation services.
Rule 205. (1) An attending physician, carrier, third-party administrator, or the injured worker may request a consultation. A physician specialist shall provide consultations using procedure codes 99241-99275 to describe the service.
(2) The carrier may request a provider other than the treating practitioner to perform a confirmatory consult. The physician specialist performing the confirmatory consult shall bill procedure codes 99271-99275, defined in “Physicians’ Current Procedural Terminology (CPT®) and shall be subject to the maximum payment allowance as defined in the reimbursement section of these rules.
(3) If a specialist performs diagnostic procedures or testing in addition to the consultation, 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.
R 418.10405 Rescinded.
R 418.10406 Rescinded.
R 418.10407 Rescinded.
R 418.10411 Rescinded.
R 418.10415 Rescinded.
PART 5. RADIOLOGY, RADIATION THERAPY, AND NUCLEAR MEDICINE
R 418.10501 Rescinded.
R 418.10502 Rescinded.
R 418.10503 Rescinded.
R 418.10901 General Information.
Rule 901. (1) All health care practitioners and health care organizations, as defined in these rules, shall submit charges on the proper claim form as specified in this rule. Copies of the claim forms and instruction for
completion for each form shall be published separate from these rules in a manual distributed by the health care services division of the bureau. Charges shall be submitted as follows:
(a) A practitioner shall submit charges on the HCFA 1500 claim form.
(b) A doctor of dentistry shall submit charges on a standard dental claim form approved by the American dental association.
(c) A pharmacy, other than an inpatient hospital, shall submit charges on an invoice or a pharmacy universal claim form.
(d) A hospital-owned occupational, industrial clinic, or office practice shall submit charges on the HCFA 1500 claim form.
(e) A hospital billing for a practitioner service shall submit charges on a HCFA 1500 claim form.
(f) Ancillary service charges shall be submitted on the HCFA 1500 claim form for durable medical equipment and supplies, L-code procedures, ambulance, vision, and hearing services. Charges for home health services shall be submitted on the UB-92 claim form.
(g) A shoe supplier or wig supplier shall submit charges on an invoice.
(2) A provider shall submit all bills to the carrier within 1 year of the date of service for consideration of payment, except in cases of litigation or subrogation.
(3) A properly submitted bill shall include all OF the following appropriate documentation:
(a) A copy of the medical report for the initial visit.
(b) An updated progress report if treatment exceeds 60 days.
(c) A copy of the initial evaluation and a progress report every 30 days of physical treatment, physical or occupational therapy, or manipulation services.
(d) A copy of the operative report or office report if billing surgical procedure codes 10040-69990.
(e) A copy of the anesthesia record if billing anesthesia codes 00100-01999.
(f) A copy of the radiology report if submitting a bill for a radiology service accompanied by modifier -26.
(g) A report describing the service if submitting a bill for a “by report” procedure.
(h) A copy of the medical report if a modifier is applied to a procedure code to explain unusual billing circumstances.
R 418.10904 Procedure codes and modifiers.
Rule 904. (1) A health care service shall be billed with procedure codes adopted from “Physicians’ Current Procedural Terminology (CPT®)” or “HCPCS, Medicare’s National Level II Codes,” as referenced in R 418.10107 of these rules. Procedure codes from “Physicians’ Current Procedural Terminology (CPT®)” shall not be included in these rules, but shall be listed in a separate manual published by the bureau. Refer to “Physicians’ Current Procedural Terminology (CPT®)” for standard billing instructions, except where otherwise noted in these rules.
(a) A provider billing services described with procedure codes from “Medicare’s National Level II Codes” shall refer to the publication as adopted by reference in R 418.10107 for coding information.
(2) The following ancillary service providers shall bill codes from “HCPCS, Medicare’s National Level II Codes” as referenced in R 418.10107 of these rules to describe the ancillary services:
(a) Ambulance providers.
(b) Certified orthotists and prosthetists.
(c) Medical suppliers, including expendable and durable equipment.
(d) Hearing aid vendors and suppliers of prosthetic eye equipment.
(3) A home health agency.
(4) If a practitioner performs a procedure that cannot be described by one of the listed CPT® or HCPCS codes, then the practitioner shall bill the unlisted procedure code. An unlisted procedure code shall only be reimbursed when the service cannot be properly described with a listed code and the documentation supporting medical necessity includes all of the following:
(a) Description of the service.
(b) Documentation of the time, effort, and equipment necessary to provide the care.
(c) Complexity of symptoms.
(d) Pertinent physical findings.
(e) Diagnosis.
(f) Treatment plan.
(5) The provider shall add a modifier code, found in Appendix A of the CPT® publication as adopted by reference in R 418.10107, following the correct procedure code describing unusual circumstances arising in the treatment of a covered injury or illness.
(a) When a modifier code is applied to describe a procedure, a report describing the unusual circumstances shall be included with the charges submitted to the carrier.
(6) Applicable modifiers from table 10904 shall be added to the procedure code to describe the type of practitioner performing the service. The required modifier codes for describing the practitioner are as follows:
Table 10904 Modifier Codes
-SA When an anesthesiologist supervises, or provides medical direction to, a certified registered nurse anesthetist or anesthesiology resident.
-AA When an anesthesiologist bills for services performed by the anesthesiologist.
-AH When a licensed psychologist bills a diagnostic service or a therapeutic service, or both.
-AJ When a certified social worker bills a therapeutic service.
-AK When a nurse who has a specialty certification, as defined in these rules, treats an injured worker and bills a service other than assistant at surgery.
-AL A limited license psychologist billing a diagnostic service or a therapeutic service.
-AU When a physician’s assistant treats an injured worker for a medical service other than assistant at surgery.
-CS When a limited licensed counselor bills for a therapeutic service.
-LC When a licensed professional counselor performs a therapeutic service.
-MF When a licensed marriage and family therapist performs a therapeutic service.
-ML When a limited licensed marriage and family therapist performs a service.
-PC When patient-controlled analgesia is provided by a physician who owns the patient- controlled analgesia equipment.
-TC When billing for the technical component of a radiology service.
-QX When a certified registered nurse anesthetist performs a service under the medical direction of an anesthesiologist.
-QZ When a certified registered nurse anesthetist performs anesthesia services without medical direction.
R 418.10909 Billing for home health services.
Rule 909. (1) Services provided by a home health agency are considered ancillary services requiring a physician’s prescription certifying medical necessity. A copy of the prescription shall be attached to the bill.
(2) A home health agency shall submit charges to the workers’ compensation carrier using the UB-92 claim form.
(3) A home health agency shall use procedure codes from “HCPCS, Medicare’s National Level II Codes” adopted by reference in R 418.10107 to identify services provided.
(4) A home health agency may not bill for the services of a social worker unless the certified social worker is providing medically necessary therapeutic counseling.
(5) A home health agency may bill supplies with 99070, the unlisted CPT® code for miscellaneous supplies, or
the appropriate supply code from “Medicare’s National Level II Codes HCPCS” as adopted by reference in R 418.10107.
(6) When a procedure code is described by “HCPCS, Medicare’s Level II” as per diem, the “by report” service is reimbursed per visit. When “HCPCS, Medicare’s Level II” describes a service as time-based the service is “by report,” and the procedure is reimbursed according to the time provided.
R 418.10912 Billing for prescription medications.
Rule 912. (1) Prescription drugs may be dispensed to an injured worker by either an outpatient pharmacy or a health care organization as defined in these rules. These rules shall apply to the pharmacy dispensing the prescription drugs to an injured worker only after the pharmacy has either written or oral confirmation from the carrier that the prescriptions or supplies are covered by workers’ compensation insurance.
(2) A bill or receipt for a prescription drug from an outpatient pharmacy, practitioner, or health care organization shall be submitted to the carrier and shall include the name, address, and social security number of the injured worker. An outpatient pharmacy shall bill the service using the universal pharmacy claim form or an invoice and shall include the national association board of pharmacy identification number and the serial number of the prescription drug.
(3) A health care organization or physician office dispensing the prescription drug shall bill the service on the HCFA 1500 claim form. Procedure code 99070 shall be used to code the service and the national drug code shall be used to describe the drug.
(4) If an injured worker has paid for a prescription drug for a covered work illness, then the worker may send a receipt showing payment along with the drug information to the carrier for reimbursement.
(5) An outpatient pharmacy or health care organization shall include all of the following information when submitting a bill for a prescription drug to the carrier:
(a) The brand or chemical name of the drug dispensed.
(b) The manufacturer or supplier’s name and the NDC, or national drug code from the “RED BOOK” as adopted by reference in R 418.10107.
(c) The dosage, strength, and quantity dispensed.
(d) The date the drug was dispensed.
(e) The physician prescribing the drug.
(6) A practitioner or a health care organization, other than an inpatient hospital, shall bill WC700 to describe the dispense fee for each prescription drug. A provider will only be reimbursed for 1 dispense fee for each prescription drug in a 10-day period. A dispense fee shall not be billed with “OTC”’s, over-the-counter drugs.
PART 9. BILLING
SUBPART A. PRACTITIONER BILLING
Rule 916. (1) This rule applies to the practitioner component of minor procedures that can safely be performed in a setting other than an outpatient hospital. If a practitioner or health care organization submits a bill for a procedure code listed in table 10916 in the outpatient hospital setting, then modifier code -26 shall be added to the procedure code and the carrier shall pay the maximum allowable fee listed in the manual for the technical portion of the procedure, or if the technical portion is not listed then the carrier shall pay 40% of the maximum allowable fee for the procedure.
(2) This rule shall not apply to any of the following instances:
(a) During an inpatient, observation stay, or services appropriately performed in the emergency room department.
(b) For procedures performed during an outpatient surgery.
(c) If procedures from table 10916 are performed during the course of an outpatient setting in conjunction with a procedure that is appropriately performed in the outpatient setting; for example, a radiology procedure with a myelogram or outpatient surgery.
(3) This rule shall not apply if the procedure is performed by an emergency room physician granted privileges by the hospital to practice in the emergency room.
(4) Table 10916 reads as follows:
TABLE 10916
10060
20665-20670
30901
65205-65222
92531-92599
10120
23065
40800
67700
93740
10140
23330
40804
67715-67805
94010-95065
10160
24065
40820
67810-67825
95115-95199
11000
24200
41000-41005
67938
95180
11040
25065
41800-41805
69000
95860-95904
11100-11101
26010
42300
69020
95930-95937
11720-11750
27040
42310
70030-70360
98925-98943
11900-11901
27086
45300
70450-71030
99195
12001-12004
27323
45330
71100-72220
99201-99215
15860
27613
46050
73000-74420
99241-99245
16000
28001
50398
74400-74420
90801-99815
16020-16030
28190
51000
78300-78699
20500
3000-30100
51700-51710
90901-90911
20520
30200-30210
53600-53661
92002-92014
20550-20610
30300
53670-53675
92230-92504
R 418.10918 Rescinded
PART 9. BILLING SUBPART B. FACILITY BILLING
R 418.10923 Hospital billing for practitioner services.
Rule 923. (1) A hospital billing for practitioner services, including a certified registered nurse anesthetist, a physician, a nurse who has a specialty certification, and a physician’s assistant shall submit bills on a HCFA 1500 form and the hospital shall use the appropriate procedure codes adopted by these rules.
(a) A hospital or hospital-system owned office practice shall bill all office services as practitioner services on a HCFA 1500 form using site of service 3 or 11.
(b) A hospital or hospital-system owned industrial or occupational clinic shall bill all clinic services as practitioner services on a HCFA 1500 using site of service 3 or 11. Radiology and laboratory services may be billed as facility services on the UB-92.
(2) A hospital billing for a radiologist’s services shall bill the professional component of the radiology procedure on the HCFA 1500 claim form and shall place modifier -26 after the appropriate radiology procedure code to identify the professional component of the service.
(3)
A hospital billing for the professional component of a pathology
service shall bill the service on a HCFA 1500 claim form and add
modifier –26.(4) A hospital billing for a certified registered nurse anesthetist shall bill only time units of an anesthesiology procedure and use modifier –QX with the appropriate anesthesia code, except in the absence of medical direction from a supervising anesthesiologist.
PART 10. REIMBURSEMENT SUBPART A. PRACTITIONER REIMBURSEMENT
R 418.101002 Conversion factors for medical, surgical, and radiology procedure codes.
Rule 1002. (1) The bureau shall determine the conversion factors for medical, surgical, and radiology procedures. The conversion factor shall be used by the bureau 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 bureau using codes adopted from “Physicians’ Current Procedural Terminology (CPT®)” as referenced in R 418.10107(a). The Bureau shall determine the relative values by using information found in the “RBRVS: Fee Schedule” as adopted by reference in R 418.10107(c).
(2) The 3 conversion factors for medicine, radiology, and surgical procedures shall be phased into 1 conversion factor. The conversion factors are listed in the following table:
Table 1002
Type of Service
Year 2000
Year 2001
Year 2002
Medicine procedure codes, 90281-99199
$41.83
$44.42
$47.01
Radiology procedure codes, 70010-79999
$46.56
$46.74
$47.01
Surgery procedure codes, 10040-69979
$48.62
$47.82
$47.01
(a) The conversion factors for year 2000 shall be effective for dates of service occurring on or after the effective date of these rules.
(b) The conversion factors for the year 2001 shall be effective for dates of service occurring on or after January 1, 2001.
(c) The single conversion factor of $47.01 shall be effective for all services occurring on or after January 1, 2002.
(3) The 1999 Relative Values adopted from “RBRVS 1999 Fee Schedule: A Plain English Guide” as adopted by reference in R 418.10107, shall be used for determining the maximum allowable payment during the phase-in period of converting to 1 conversion factor. If new procedure codes are added into “Physicians’ Current Procedural Terminology, (CPT®)” as adopted by reference in R 418.10107, then the relative value and global period listed in the most recent edition of the “Medicare RBRVS Fee Schedule: A Physicians’ Guide” as
adopted by reference in R 418.10107 shall be used by the bureau to determine the maximum allowable payment for new procedure codes not listed in the “RBRVS 1999 Fee Schedule: A Plain English Guide.”
R 418.101005 Reimbursement for home health services.
Rule 1005. (1) Home health services are reimbursed “by report”, requiring submission of a report with the charges on the UB-92 claim form. The carrier shall reimburse the home health agency according to each “by report” procedure listed on the UB-92, billed with the appropriate HCPCS code in accord with R 418.10909.
(2) Home health services shall be reimbursed by the carrier at either the provider’s usual and customary charge as defined by these rules or reasonable amount, whichever is less.
(3) Services listed in “HCPCS, Medicare Level II Codes” as adopted by reference in R 418.10107 as per diem shall be reimbursed per diem or per visit in accord with the description of the code. The per diem visit shall be either at the provider’s usual and customary charge or reasonable amount, whichever is less.
(4) When a home health agency bills for supplies on the UB-92, the supplies shall be reimbursed at AWP, average wholesale price plus not more than a 50% markup above average wholesale price.
