3 ADMINISTRATIVE RULES

 

ORR # 2004-037 WORKERS’ COMPENSATION AGENCY

DEPARTMENT OF LABOR & ECONOMIC GROWTH WORKER’S COMPENSATION HEALTH CARE SERVICES

 

Filed with the Secretary of State on February 2, 2005.

These rules take effect 7 days after filing with the Secretary of State

 

(By authority conferred on the worker's compensation agency 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 418.10101, R 418.10103, R 418.10104, R 418.10107, R 418.10108, R 418.10109, R 418.10110, R

418.10111,  R 418.10115,  R 418.10117,  R  418.10118,  R 418.10120,  R 418.10404,  R 418.10701,

R 418.10901, R 418.10902, R 418.10904, R 418.10907, R 418.10912, R 418.10915, R 418.10921, R

418.10923, R 418.10925, R 418.101001, R 418.101002, R 418.101003, R 418.101004, R 418.101015,

R 418.101016,    R 418.101017,    R 418.101022,    R    418.101101,    R    418.101102,    R 418.101103,

R 418.101104,    R 418.101105,    R    418.101204,    R    418.101205,      R 418.101206,    R 418.101207,

R 418.101208,   R   418.101209,   R   418.101210,   R 418.101301,   R 418.101303,   R 418.101304,   R

418.101305,    R    418.101401,   R 418.101402,   R 418.101404,   R 418.101501,    R    418.101502   and

R 418.101503 are amended, R 418.10923B and R 418.101023 are added to the Administrative code.

PART 1. GENERAL PROVISIONS R 418.10101 Scope.

Rule 101. (1) These rules do all of the following:

(a)      Establish procedures by which the employer shall furnish, or cause to be furnished, to an employee who receives a personal injury arising out of and in the course of employment, reasonable medical, surgical, and hospital services and medicines, or other attendance or treatment recognized by the laws of the state as legal, when needed. The employer shall also supply to the injured employee dental services, crutches, artificial limbs, eyes, teeth, eyeglasses, hearing apparatus, and other appliances necessary to cure, so far as reasonably possible, and relieve from the effects of the injury.

(b)      Establish schedules of maximum fees by a health facility or health care provider for such treatment or attendance, service, device, apparatus, or medicine.

(c)    Establish procedures by which a health care provider shall be paid.

(d)     Provide for the identification of utilization of health care and health services above the usual range of utilization for such services, based on medically accepted standards, and provide for acquiring by a carrier and by the workers’ compensation agency the necessary records, medical bills, and other information concerning any health care or health service under review.

 

 

(e)    Establish a system for the evaluation by a carrier of the appropriateness in terms of both the level of and the quality of health care and health services provided to injured employees, based upon medically accepted standards.

(f)    Authorize carriers to withhold payment from, or recover payment from, health facilities or health care providers, which have made excessive charges or which have required unjustified treatment, hospitalization, or visits.

(g)     Provide for the review by the workers’ compensation agency of the records and medical bills of any health facility or health care provider which have been determined by a carrier not to be in compliance with the schedule of charges established by these rules or to be requiring unjustified treatment, hospitalization, or office visits.

(h)     Provide for the certification by the workers’ compensation agency of the carrier’s professional utilization review program.

(i)     Establish that when a health care facility or health care provider provides health care or health care service that is not usually associated with, is longer in duration than, is more frequent than, or extends over a greater number of days than that health care or service usually does with the diagnosis or condition for which the patient is being treated, the health facility or health care provider may be required by the carrier to explain the necessity in writing.

(j)    Provide for the interaction of the workers’ compensation agency and the department of labor and economic growth for the utilization of departmental procedures for the resolution of workers’ compensation disputes.

(k)    Are intended for the implementation and enforcement of section 315(2) to (9) of the act, provide for the implementation of the workers’ compensation agency’s review and decision responsibility vested in it by those statutory provisions. The rules and definitions are not intended to supersede or modify the workers’ disability compensation act, the administrative rules of practice of the workers’ compensation agency, or court decisions interpreting the act or the workers’ compensation agency’s administrative rules.

(2)   An independent medical examination shall be exempt from these rules and may be requested by a carrier or an employee. An independent medical examination, (IME), shall be conducted by a practitioner other than the treating practitioner. Reimbursement for the independent medical evaluation shall be based on a contractual agreement between the provider of the independent medical evaluation and the party requesting the examination.

(3)   These rules and the fee schedule shall not pertain to health care services which are rendered by an employer to its employee in an employer-owned and employer-operated clinic.

(4)   If a carrier and a provider have a contractual agreement designed to reduce the cost of workers’ compensation health care services below what would be the aggregate amount if the fee schedule were applicable, the contractual agreement shall be exempt from the fee schedule. The carrier shall be required to do both of the following:

(a)    Perform technical and professional review procedures.

(b)     Provide the annual medical payment report to the health care services division of the workers’ compensation agency.

 

R 418.10103 Complaints.

Rule 103. Any person who is affected by these rules may submit a written complaint to the workers’ compensation agency regarding the actions of any other person who is affected by these rules.

 

R 418.10104   Reimbursement to injured worker or to health insurer for compensable medical services.

 

 

Rule 104. (1) Notwithstanding any other provision of these rules, if an injured worker has paid for a health care service and at a later date a carrier is determined to be responsible for the payment, then the injured worker shall be fully reimbursed by the carrier.

(2)  The injured worker may submit the request for reimbursement on a medical or dental claim form, but shall supply to the carrier a copy of a statement including the provider name, the date of service, the procedure and diagnosis and documentation of the amount paid.

(3)   When a health insurer pays for a medical service to treat an injured worker and subsequently requests reimbursement from the workers’ compensation carrier, the health insurer is not required to submit the request on a CMS 1500, or a UB-92 claim form, or other medical or dental claim form. The health insurer shall supply to the workers’ compensation carrier, or the carrier’s designee, a claim detail showing the date of service, the amount billed and paid, the procedure code and diagnosis for the rendered services. The workers’ compensation carrier shall reimburse the health insurer the provider’s usual and customary fee or the maximum allowable fee, whichever is less, for the compensable medical services in accordance with these rules. If the health insurer reimbursed the provider less than the amount allowed by these rules, then the workers’ compensation carrier shall reimburse the amount paid by the health insurer.

 

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 at, or purchase from, the workers' compensation agency, 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®) 2005," standard edition, copyright October 2004, published by the American Medical Association, PO Box 930876, Atlanta GA, 31193-0876, order

# OP054105CFJ ISBN: 1-57947-578-7, 1-800-621-8335. The publication may be purchased at a cost of

$62.95, plus $9.95 for 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, 2005," copyright November 2004, published by the American Medical Association, P.O. Box 930876 Atlanta GA 31193-0876, order # OP095105CFJ ISBN: 1-57947-571-X, customer service 1-800-621-8335. The publication may be purchased at a cost of $89.95, plus $11.95 for shipping and handling as of the time of adoption of these rules.

(c)       “Medicare RBRVS 2004: The Physicians’ Guide,” published by the American Medical Association, 515 North State Street, Chicago IL, 60610, 1-800-621-8335. The publication may be purchased at a cost of $79.95, plus $11.95 shipping and handling as of the time of adoption of these rules.

(d)      “Medicare RBRVS 2005: The Physicians’ Guide,” published by The American Medical Association, 515 North State Street, Chicago Il, 60610, order #OPO59605CFJ, 1-800-621-8335. The publication may be purchased at a cost of $84.95, plus $11.95 shipping and handling as of the time of adoption of these rules.

(e)      "International Classification of Diseases, ICD-9-CM 2005 Volumes 1 & 2" copyright 2004, American Medical Association, P.O. Box 930876, Atlanta GA 31193-0876, order #OP068105CFJ, 1- 800-621-8335. The publication may be purchased at a cost of $64.95, plus $9.95 shipping and handling as of the time of adoption of these rules.

(f)    "2004 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

$75.95, plus $9.95 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, Attn: UB-92 Subscriptions, 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 $160.00, plus 6% sales tax.

 

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 labor & economic growth.

(d)    “Appropriate care” means health care that is suitable for a particular person, condition, occasion, or place.

(e)     “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.

(f)       “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.

(g)    “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.

(h)    “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.

(i)    “Complete procedure” means a procedure that contains a series of steps that are not to be billed separately.

(j)    “Covered injury or illness” means an injury or illness for which treatment is mandated by section 315 of the act.

(k)     “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.

(l)    “Dispute” means a disagreement between a carrier or a carrier’s agent and a health care provider on the application of these rules.

(m)    “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.

(n)      “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.

(o)    “Established patient” means a patient whose medical and administrative records for a particular covered injury or illness are available to the provider.

(p)    “Expendable medical supply” means a disposable article that is needed in quantity on a daily or monthly basis.

(q)    “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.

(r)     “Focused review” means the evaluation of a specific health care service or provider to establish patterns of use and dollar expenditures.

 

 

(s)    “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.

(t)      “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.

(u)     “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.

(v)    “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.

(w)    “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.

(x)    “Independent procedure” means a procedure that may be carried out by itself, separate and apart from the total service that usually accompanies it.

(y)      “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.

(z)     “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 provisions of 1885 PA 152, MCL 36.1 et seq.

(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 et seq.

(l)    “Primary procedure” means the therapeutic procedure that is most closely related to the principal diagnosis.

(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)      “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.

(t)      “Subrogation” means substituting one 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.

(u)    “Technical surgical assist” means that additional payment for an assistant surgeon, referenced in R 418.10416 of these rules, 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.”

(v)     “Treatment plan” means a plan of care for restorative physical treatment services that indicates the diagnosis and anticipated goals.

 

 

(w)    “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 418.10110 Program Information.

Rule 110. The workers’ compensation agency shall provide ongoing information regarding these rules for providers, carriers, and employees. The program shall include distribution of appropriate information materials. The health care services division shall provide periodic informational sessions for providers, billing organizations, and carriers.

 

R 418.10111 Advisory committee.

Rule 111. The director of the workers’ compensation agency shall appoint an advisory committee from names solicited from provider, carrier, and employee organizations. The advisory committee shall include five advocates for the concerns of providers, five advocates for the concerns of employees, and five advocates for the concerns of carriers. The director of the workers’ compensation agency shall appoint a sixteenth member to act as chair without a vote. The advisory committee shall meet not less than twice a year. Additional meetings shall be scheduled if requested by the workers’ compensation agency, the chair, or a majority of the committee. Members may be removed by the director of the workers’ compensation agency for cause or for missing more than one-half of the meetings in a year. The advisory committee shall perform general program oversight and assist the workers’ compensation agency with the following:

(a)    Annual review of the rules and the fee schedule.

(b)       Development of proposed amendments to the rules and fee schedule, including payment methodologies.

(c)    Review of data reports and data analyses.

(d)     Review health care service disputes, resulting from a carrier’s professional health care review program pursuant to these rules, that are considered by mediation, arbitration, small claims, or magistrate decisions, based on annual summary data regarding such disputes. This summary data shall be developed by the agency and shall include information regarding carriers and providers which accounts for a significant number of disputes.

(e)    Review annual summary data of complaints made to the workers’ compensation agency.

 

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 workers’ compensation agency 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 418.10117 Carrier responsibilities.

Rule 117. (1) The carrier or its designated agent shall assure that a billing form is completed properly before making payment to the licensed provider or licensed facility.

(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 record payment decisions on a form entitled “The Carrier’s Explanation of Benefits” using a format approved by the workers’ compensation agency. The carrier or designated agent shall keep a copy of the explanation of benefits and shall send a copy to the provider and to the injured worker. The carrier’s explanation of benefits shall list a clear reason for the payment adjustment or amount disputed and shall notify the provider what information is required for additional payment.

(5)  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.

(6)   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.

(7)   When the carrier has disputed a case and has not issued a copy of the formal notice of dispute to the medical provider, then the carrier’s explanation of benefits shall be sent in response to the provider’s initial bill. The carriers’ explanation of benefits shall serve as notice to the provider that non-payment of the bill is due to the dispute.

 

R  418.10118    Practitioner, facility, and health care organization copying charge for medical records.

Rule 118. (1) A practitioner, facility, or health care organization shall, at the request of the carrier, the carrier’s agent, the employee, or the employee’s agent, furnish copies of the case record for a particular covered injury or illness to the carrier, the carrier’s agent, the employee, or the employee’s agent. The maximum fee for providing copies shall be 45 cents per page, plus the actual cost of mailing. In addition, an administration charge for the staff’s time to retrieve and copy the records shall be paid as follows:

0-15 minutes                                                          $2.50

Each additional 15 minute increment                    $2.50

 

The copying and handling charge shall apply to all reports and records, other than the original copy required pursuant to the provisions of R 418.10113, and all other reports required by these rules. The party who requests the records shall pay the copying charge.

 

 

(2)   The copying charge for each x-ray film requested by the carrier or the carrier’s agent shall be reimbursed at $15.00, which includes mailing and handling.

(3)   If an agent of a carrier or an employee requests a copy of the case record, then the agent shall indicate the date of injury. Only the records for a specific date of injury covered by the act and these rules are available as specified in subrule (1) of this rule.

 

R 418.10120 Recovery of payment.

Rule 120. (1) Nothing in this rule shall preclude the recovery of payment for services and bills which may later be found to have been medically inappropriate or paid at an amount that is more than the maximum allowable payment.

(2)   If the carrier makes a request to the provider for the recovery of a payment within 1 year of the date of payment and includes a statement of the reasons for the request, then the carrier may recover a payment. The carrier may recover a payment made by an employee or the carrier.

(3)   Within 30 days of receipt of the carrier’s request for recovery of the payment, the provider shall do either of the following:

(a)    If the provider is in agreement with the request, then the provider shall refund the payment to the carrier.

(b)     If the provider is not in agreement with the request, then the provider shall supply the carrier with a written detailed statement of the reasons for its disagreement, together with a refund of the portion, if any, of the payment that the provider agrees should be refunded.

(4)    If the carrier does not accept the reason for disagreement supplied by the provider, then the carrier may file an application for mediation or hearing as provided for in R 418.101303 and R 418.101304. Within 30 days of receipt of the provider’s statement of disagreement, the carrier shall file the application for mediation or hearing with the workers’ compensation agency and the carrier shall mail a copy to the provider.

(5)   If, within 60 days of the carrier’s request for recovery of a payment, the carrier does not receive either a full refund of the payment or a statement of disagreement, then, at the option of the carrier, the carrier may do either or both of the following:

(a)    File an application for mediation or hearing and mail a copy to the provider.

(b)     Reduce the payable amount on the provider’s subsequent bills to the extent of the request for recovery of payment.

(6)    If, within 30 days of a final order of a magistrate, the appellate commission, or the courts, a provider does not pay in full any refund ordered, then the carrier may reduce the payable amount on the provider’s subsequent bills to the extent of the request for recovery of payment.

 

PART 4. SURGERY

 

R 418.10404 Follow-up care occurring during global service.

Rule 404. (1) Follow-up care for a diagnostic procedure shall refer only to the days required to recover from the diagnostic procedure and not the treatment of the underlying condition.

(2)   Follow-up care for therapeutic surgical procedures includes only that care which is usually part of the surgical service. Complications, exacerbations, recurrence, or the presence of other compensable diseases or injuries requiring additional services should be reported with the identification of appropriate procedures. The follow-up days for the surgical procedures are adopted from the “Medicare RBRVS The Physicians Guide” as referenced in R 418.10107(d). The follow-up days for each surgical procedure are identified in the "global" column in the manual published by the workers’ compensation agency separate from these rules.

 

 

(a)    If a carrier requests the surgeon to see an injured worker during the global service period for the purpose of job restrictions, job adjustments, or return to work, then the visit shall not be considered part of the global surgery package. If the carrier requests the visit, then the carrier shall prior authorize the visit assigning an authorization number. The provider shall bill the visit using procedure 99455 and modifier –32, including the authorization number in box 23 of the CMS 1500 form. The carrier shall not deny a prior authorized visit and shall reimburse the provider for the prior authorized visit. The maximum allowable payment for 99455-32 shall be listed in rule R 418.101502.

(b)    The medical record shall reflect job adjustments, job restrictions or limitations, or return to work date and the provider shall include the medical record with the bill.

(c)     If an insured employer requests the surgeon to see an injured worker during the global surgery period for the purpose of job adjustments, restrictions, or return to work, then the employer shall obtain the prior authorization number from the carrier for the visit.

(3)   Hospital follow-up care or a hospital visit by the practitioner responsible for the surgery shall be considered part of the surgical follow-up days listed for the procedure and shall not be paid as an independent procedure.

 

PART 7. DENTAL

 

R 418.10701 Scope.

Rule 701. (1) Dental services, related to, or resulting from, a covered work-related injury are covered under these rules. Incidental dental services are not covered.

(2)   A dental provider shall bill services on a standard American dental claim form. The workers’ compensation agency shall publish a copy of the claim form and instructions for completion separate from these rules in the health care services manual.

(3)   Dental services shall be reimbursed at either the dentist’s usual and customary fee or reasonable fee, whichever is less.

 

 

PART 9. BILLING

SUBPART A. PRACTITIONER BILLING

 

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 workers' compensation agency. Charges shall be submitted as follows:

(a)    A practitioner shall submit charges on the CMS1500 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 CMS 1500 claim form.

(e)    A hospital billing for a practitioner service shall submit charges on a CMS 1500 claim form.

 

 

(f)     Ancillary service charges shall be submitted on the CMS 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. The carrier shall only reimburse the radiologist for the written report, or professional component, upon receipt of a bill for the radiology procedure.

(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 418.10902 Billing for injectable medications, other than vaccines and toxoids, in office setting.

Rule 902. (1) The provider shall not bill the carrier for procedure codes 90782-90799, administration of therapeutic injections, if billed in conjunction with an evaluation and management procedure code. If an evaluation and management procedure code, 99201-99499, is not listed, then procedure codes 90782- 90799 may be billed to describe the administration of the medication.

(2)    The injection medication shall be billed with either 99070, the unlisted drug and supply code from physicians’ current procedural terminology, (CPT®), or the specific J-code procedure from Medicare’s National Level II Codes as adopted by reference in R 418.10107.

(3)   The provider shall list the NDC or national drug code for the medication in box 19 or 24K of the CMS 1500.

(4)   The carrier shall reimburse the medication at average wholesale price, (AWP) according to the Redbook, as adopted by reference in R 418.10107.

(5)   If the provider does not list the national drug code for the medication, the carrier shall reimburse the medication using the least costly NDC listed by Redbook for that medication.

 

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. 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 workers’ compensation agency. Refer to “Physicians’ Current Procedural Terminology (CPT®)” for standard billing instructions, except where otherwise noted in these rules. 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 adopted by reference in R 418.10107, 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. 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

-AA      Anesthesia services performed personally by 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.

-AL       A limited license psychologist billing a diagnostic service or a therapeutic service.

-CS       When a limited licensed counselor bills for a therapeutic service.

-GF       Non-physician (nurse practitioner, advanced practice nurse or physician assistant) provides services in an office or clinic setting or in a hospital setting.

-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.

-TC        When billing for the technical component of a radiology service.

-QK               When  an  anesthesiologist  provides  medical  direction  for  not  more  than  4  qualified individuals being either certified registered nurse anesthetists or anesthesiology residents

-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 418.10907 Billing codes for site of service and type of service.

Rule 907. (1) A practitioner, other than a dentist, when billing practitioner services, shall identify the

 

 

site of service and type of service with numerical codes consistently used in the industry. The health care services division of the workers’ compensation agency shall publish the numerical codes in the Health Care Services Manual separate from these rules.

 

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)   When a generic drug exists, the generic drug shall be dispensed. When a generic drug does not exist, the brand name drug may be dispensed. A physician may only write a prescription for “DAW”, or dispense as written, when the generic drug has been utilized and found to be ineffective or has caused adverse effects for the injured worker. A copy of the medical record documenting the medical necessity for the brand name drug shall be submitted to the carrier.

(3)   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.

(4)    A health care organization or physician office dispensing the prescription drug shall bill the service on the CMS 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.

(5)   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.

(6)   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.

(7)   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.

 

R 418.10915 Billing for anesthesia services.

Rule 915. (1) Anesthesia services shall consist of 2 components. The 2 components are base units and time units. Each anesthesia procedure code is assigned a value for reporting the base units. The base units for an anesthesia procedure shall be as specified in the publication entitled “Medicare RBRVS: The Physicians’ Guide” as adopted by reference in R 418.10107. The anesthesia codes, base units and instructions for billing the anesthesia service shall be published separate from these rules in the health care services manual.

(2)   An anesthesia service may be administered by either an anesthesiologist, anesthesia resident, a certified registered nurse anesthetist, or a combination of a certified registered nurse anesthetist, and a

 

 

physician providing medical direction or supervision. When billing for both the anesthesiologist and a certified registered nurse anesthetist, the anesthesia procedure code shall be listed on 2 lines of the CMS 1500 with the appropriate modifier on each line.

(3)   One of the following modifiers shall be added to the anesthesia procedure code to determine the appropriate payment for the time units:

(a)    Modifier -AA indicates the anesthesia service is administered by the anesthesiologist.

(b)      Modifier –QK indicates the anesthesiologist has provided medical direction for a certified registered nurse anesthetist, CRNA, or resident. The CRNA or resident may be employed by either a hospital, the anesthesiologist or may be self-employed.

(c)     Modifier -QX indicates the certified registered nurse anesthetist has administered the procedure under the medical direction of the anesthesiologist.

(d)    Modifier -QZ indicates the certified registered nurse anesthetist has administered the complete anesthesia service without medical direction of an anesthesiologist.

(4)   Total anesthesia units shall be calculated by adding the anesthesia base units to the anesthesia time units.

(5)   Anesthesia services may be administered by any of the following:

(a)    A licensed doctor of dental surgery.

(b)    A licensed doctor of medicine.

(c)    A licensed doctor of osteopathy.

(d)    A licensed doctor of podiatry.

(e)    A certified registered nurse anesthetist.

(f)    A licensed anesthesiology resident.

(6)   If a surgeon provides the anesthesia service, the surgeon will only be reimbursed the base units for the anesthesia procedure.

(7)   If a provider bills physical status modifiers, then documentation shall be included with the bill to support the additional risk factors. When billed, the physical status modifiers are assigned unit values as defined in the following table:

 

Anesthesiology Physical Status Modifiers                         Unit Value

P1    A normal healthy patient.                                                                                            0

P2    A patient who has a mild systemic disease.                                                                0

P3    A patient who has a severe systemic disease.                                                             1

P4    A patient who has a severe systemic disease that is a constant threat to life.            2

P5    A moribund patient who is expected not to survive without the operation.              3

P6    A  declared  brain-dead  patient  whose  organs  are  being  removed  for  donor     0 purposes.

 

(8)    Procedure code 99140 shall be billed as an add-on procedure if an emergency condition, as defined in R 418.10108, complicates anesthesia. Procedure code 99140 shall be assigned 2 anesthesia units. Documentation supporting the emergency shall be attached to the bill.

(9)   If a pre-anesthesia evaluation is performed and surgery is not subsequently performed, then the service shall be reported as an evaluation and management service.

 

PART 9. BILLING

SUBPART B. FACILITY BILLING

 

R 418.10921 Facility billing.

 

 

Rule 921. (1) Except for a freestanding surgical outpatient facility, a licensed facility as defined in these rules shall submit facility charges on a UB-92 claim form to the carrier. A copy of the UB-92 form shall be published separate from these rules in a manual distributed by the health care services division of the agency. The Michigan uniform billing manual referenced in these rules contains instructions for facility billing.

(2) A facility billing for a practitioner service shall bill charges on the CMS 1500 claim form.

 

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 CMS 1500 form and the hospital shall use the appropriate procedure codes adopted by these rules. A hospital shall bill for professional services provided in the hospital clinic setting as practitioner services on a CMS 1500 form using outpatient hospital for the site of service. A hospital or hospital system-owned office practice shall bill all office services as practitioner services on a CMS 1500 form using office or clinic for the site of service. A hospital or hospital system-owned industrial or occupational clinic providing occupational health services for  injured workers shall  bill all clinic services as practitioner services on a CMS 1500 using office or clinic for the site of service. A hospital or hospital system-owned industrial or occupational clinic shall not use emergency department evaluation and management procedure codes. Radiology and laboratory services may be billed as facility services on the UB-92.

(2)    A hospital billing for the professional component of a medical service, excluding physical medicine, occupational medicine, or speech and hearing services shall bill the service on a CMS 1500 claim form adding modifier –26 identifying the bill is for the professional component of the service. The bill shall indicate outpatient hospital for the site of service. The carrier shall pay the maximum allowable fee listed in the manual for the professional component of the procedure. If the professional component is not listed, then the carrier shall pay 40% of the maximum allowable fee.

(3)     A hospital billing for a radiologist’s or pathologist’s services shall bill the professional component of the procedure on the CMS 1500 claim form and shall place modifier -26 after the appropriate procedure code to identify the professional component of the service. The carrier shall pay the maximum allowable fee listed in the manual for the professional component of the procedure. If the professional component is not listed, then the carrier shall pay 40% of the maximum allowable fee.

(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.

 

R 418.10923B Billing for freestanding surgical outpatient facility,(FSOF).

Rule 923B (1) A freestanding surgical outpatient facility (FSOF) shall be licensed by the department of public health, bureau of health systems, under part 208 of the code. The owner or operator of the facility shall make the facility available to other physicians, dentists, podiatrists or providers who comprise its professional staff.

(a)      When a surgery procedure is appropriately performed in the freestanding surgical outpatient facility and Medicare has not assigned a grouper number for that procedure, the procedure shall be considered by report. The freestanding surgical outpatient facility shall be reimbursed either the usual and customary charge or reasonable charge, whichever is less for the procedure.

(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)   A freestanding surgical outpatient facility, licensed by the state, 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 FSOF claim. Procedures performed bilaterally shall be billed on two separate lines of the claim form and shall be identified with modifiers, LT for left and RT for right.

(5)   A freestanding surgical outpatient facility 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 CPT® procedure code billed by the facility is classified according to 1 of 9 groupers, as determined by center for Medicare and Medicaid services. The grouper number for each procedure code is published in the federal register.

(7)   The payment for the surgical code includes the supplies for the procedure.

(8)   Laboratory procedures, durable medical equipment, radiology services, and items implanted into the body that remain in the body at discharge from the facility may be billed separately.

(9)    The facility shall bill implant items with the unlisted CPT® drug and supply code, 99070. A report listing a description of the implant and a copy of the facility’s cost invoice shall be included with the bill. Some examples of implant items are plates, pins, screws, mesh.

(10)   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 postoperative radiology services may be globally billed.

(11)   At no time shall the freestanding surgical outpatient facility bill for practitioner services on the facility bill.

 

R 418.10925 Billing requirements for other licensed facilities.

Rule 925. (1) A licensed facility, other than a hospital or freestanding surgical outpatient facility, shall bill the facility services on the UB-92 national uniform billing claim form and shall include the revenue codes contained in the Michigan Uniform Billing Manual, ICD-9-CM coding for diagnoses and procedures, and CPT® procedure codes for surgical, radiological, laboratory, and medicine and evaluation and management services.

(2)   Only the technical component of a radiological service or a laboratory service shall be billed on the standardized UB-92 national uniform billing claim form.

(3)    All bills for the professional services shall be billed on a CMS 1500 claim form, using the appropriate CPT® procedure code and modifier

(4)   A report describing the services provided and the condition of the patient shall be included with the bill.

 

PART 10. REIMBURSEMENT

SUBPART A. PRACTITIONER REIMBURSEMENT

 

R 418.101001 General rules for practitioner reimbursement.

Rule 1001. (1) A provider that is authorized to practice in the state of Michigan shall receive the maximum allowable payment in accordance with these rules. A provider shall follow the process specified in these rules for resolving differences with a carrier regarding payment for appropriate health care services rendered to an injured worker.

 

 

(2)   A carrier shall not make a payment for a service unless all required review activities pertaining to that service are completed.

(3)   A carrier’s payment shall reflect any adjustments in the bill made through the carrier’s utilization review program.

(4)    A carrier shall pay, adjust, or reject a properly submitted bill within 30 days of receipt. The carrier shall notify the provider on a form entitled “Carrier’s Explanation of Benefits” in a format specified by the workers’ compensation agency. A copy shall be sent to the injured worker.

(5)    A carrier shall not make a payment for any service which is determined inappropriate by the carrier’s professional health care review program.

(6)    The carrier shall reimburse the provider a 3% late fee if more than 30 calendar days elapse between a carrier’s receipt of a properly submitted bill and a carrier’s mailing of the payment.

(7)    If a procedure code has a maximum fee of “by report,” the provider shall be paid usual and customary charge or the reasonable amount, whichever is less. The carrier shall provide an explanation of its determination that the fee is unreasonable or excessive in accordance with these rules.

 

R 418.101002 Conversion factors for medical, surgical, and radiology procedure codes.

Rule 1002. (1) The workers' compensation agency shall determine the conversion factors  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 $48.49 for the year 2005 and shall be effective for dates of service on or after the effective date of these rules.

 

R 418.101003 Reimbursement for “by report” and ancillary procedures.

Rule 1003. (1) If a procedure code does not have a listed relative value or is noted BR, then the carrier shall reimburse the provider’s usual and customary charge or reasonable payment, whichever is less, unless otherwise specified in these rules.

(2)   The following ancillary services are by report and the provider shall be reimbursed either at the practitioner’s usual and customary charge or reasonable payment, whichever is less:

(a)    Ambulance services.

(b)    Dental services.

(c)    Vision and prosthetic optical services.

(d)    Hearing aid services.

(3)    Prescription medication shall be reimbursed at the average wholesale price (AWP) + a $4.00 dispense fee for each drug, as determined by the Red Book, referenced in R 418.10107(e).

(4)     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.

(5)   Durable medical equipment, supplies, including pre-fabricated splints, shall be reimbursed by the carrier at the average wholesale price, plus not more than 50%, or the provider’s usual and customary charge, whichever is less.

 

 

(6)   Orthotic and prosthetic procedures, L0100-L8499, and assigned maximum allowable payments shall be listed in R 418.101504.

 

R 418.101004 Modifier code reimbursement.

Rule 1004. (1) When accompanied by a modifier code, a procedure code shall be considered to have a maximum allowable payment of BR, except as provided for by subrules (2) to (13) of this rule.

(2)      When modifier code -25 is added to an evaluation and management procedure code, reimbursement shall only be made when the documentation provided supports the patient’s condition required a significant separately identifiable evaluation and management service other than the other service provided or beyond the usual preoperative and postoperative care.

(3)     When modifier code -26, professional component, is used with a radiology procedure, the payment shall be determined by multiplying the relative value for the professional component times the radiology conversion factor.

(4)    If a surgeon uses modifier code -47 when performing a surgical procedure, then anesthesia services were provided by the surgeon and the maximum allowable payment for the anesthesia portion of the service shall be calculated by multiplying the base unit of the appropriate anesthesia code by

$42.00. No additional payment is allowed for time units.

(5)   When modifier code -50 or -51 is used with procedure codes 10000-69999, a doctor of dental surgery, doctor of medicine, doctor of osteopathy, or doctor of podiatry shall be paid the following:

(a)     The primary procedure at not more than 100% of the maximum allowable payment or the billed charge, whichever is less.

(b)    The secondary procedure and the remaining procedure or procedures at not more than 50% of the maximum allowable payment or the billed charge, whichever is less.

(c)     When multiple injuries occur in different areas of the body, the first surgical procedure in each part of the body shall be reimbursed 100% of the maximum allowable payment or billed charge, whichever is less, and the second and remaining surgical procedure or procedures shall be identified by modifier code -51 and shall be reimbursed at 50% of the maximum allowable payment or billed charges, whichever is less.

(d)    When modifier -50 or -51 is used with a surgical procedure with a maximum allowable payment of BR, the maximum allowable payment shall be 50% of the provider’s usual and customary charge or 50% of the reasonable amount, whichever is less.

(6)    When modifier code -TC, technical services, is used to identify the technical component of a radiology procedure, payment shall be made for the technical component only. The maximum allowable payment for the technical portion of the radiology procedure is designated in the manual by -TC.

(7)      When modifier -57, initial decision to perform surgery, is added to an evaluation and management procedure code, then modifier -57 shall indicate that a consultant has taken over the case and the consultation code is not part of the global surgical service.

(8)   When both surgeons use modifier -62 and the procedure has a maximum allowable payment, the maximum allowable payment for the procedure shall be multiplied by 25%. Each surgeon shall be paid 50% of the maximum allowable payment times 25%, or 62.5 % of the MAP. If the maximum allowable payment for the procedure is BR, then the reasonable amount shall be multiplied by 25% and be divided equally between the surgeons.

(9)    When modifier code -80 is used with a procedure, the maximum allowable payment for the procedure shall be 20% of the maximum allowable payment listed in these rules, or the billed charge, whichever is less. If a maximum payment has not been established and the procedure is BR, then payment shall be 20% of the reasonable payment amount paid for the primary procedure.

 

 

(10)   When modifier code -81 is used with a procedure code that has a maximum allowable payment, the maximum allowable payment for the procedure shall be 13% of the maximum allowable payment listed in these rules or the billed charge, whichever is less.  If modifier code -81 is used with a BR procedure, then the maximum allowable payment for the procedure shall be 13% of the reasonable amount paid for the primary procedure.

(11)   When modifier -82 is used and the assistant surgeon is a licensed doctor of medicine, doctor of osteopathic medicine and surgery, doctor of podiatric medicine, or a doctor of dental surgery, the maximum level of reimbursement shall be the same as for modifier -80. If the assistant surgeon is a physician’s assistant, the maximum level of reimbursement shall be the same as modifier -81. If a person other than a physician or a certified physician’s assistant bills using modifier -82, then the charge and payment for the service is reflected in the facility fee.

(12)   When modifier –GF is billed with evaluation and management or minor surgical services, the carrier shall reimburse the procedure at 85% of the maximum allowable payment, or the usual and customary charge, whichever is less.

 

PART 10. REIMBURSEMENT

SUBPART B. FACILITY REIMBURSEMENT

 

R 418.101015 General rules for facility reimbursement.

Rule 1015. (1) A facility licensed by the state of Michigan shall receive the maximum allowable payment in accordance with these rules. The facility shall follow the process specified in these rules for resolving differences with a carrier regarding payment for the appropriate health care services rendered to an injured worker.

(2)    The carrier or its designated agent shall assure that the UB-92 national uniform billing claim form, (D1450), is completed correctly before payment. A carrier’s payment shall reflect any adjustments in the bill made through the carrier’s utilization review program.

(3)   A carrier shall pay, adjust or reject a properly submitted bill within 30 days of receipt, sending notice on a form entitled “ Carrier’s Explanation of Benefits” in a format specified by the agency. The carrier shall reimburse the facility a 3% late fee if more than 30 days elapse between a carrier’s receipt of a properly submitted bill and a carrier’s mailing of the payment.

(4)    Submission of a correctly completed UB-92 claim form shall be considered to be a properly submitted bill. The following medical records shall also be attached to the facility charges as applicable:

Emergency room report.

The initial evaluations and progress reports every 30 days whenever physical medicine, speech and hearing services are billed by a facility.

The anesthesia record whenever the facility bills for the services of a CRNA or anesthesiologist.

(5)   Additional records not listed in subrule (4) of this rule may be requested by the carrier and shall be reimbursed in accordance with R 418.10118.

 

R 418.101016 Reimbursement for hospital facility services.

Rule 1016. (1) A hospital licensed in Michigan billing facility services shall be reimbursed using the maximum payment ratio methodology for the following services:

Inpatient or observation care. Emergency department services.

(c)     Occupational, physical, and speech therapy services.

(d)    Outpatient surgeries.

(e)      Laboratory services and outpatient services not listed on Table 10922.

 

 

If a carrier pays a properly submitted bill or unadjusted portion of the bill within 30 days of receipt, then the payment is calculated by multiplying the charges times the hospital’s maximum payment ratio times a multiplier of 107%. If a carrier pays the bill after 30 days, then the multiplier shall be 110% allowing for a 3% late fee.

(2)   When a hospital outside the state of Michigan submits a bill for facility services, the carrier may initially process payment by using the method described in subrule (1) applying the average maximum payment ratio, as published in the health care services manual. If the facility located outside of Michigan does not accept reimbursement according to Michigan health care services rules, then the carrier shall negotiate the charges with the out-of-state facility and reimburse the facility according to the laws of the state where the facility is located.

(3)    If applying the ratio methodology results in an amount greater than the hospital’s charge, the carrier shall reimburse the hospital’s charge. The only time a carrier shall pay in excess of the charge is if a properly submitted bill was not paid within 30 days and, in that instance, the carrier shall reimburse the charge plus a 3% late fee.

(4)    Observation care shall not be for more than 24 hours. If the patient does not meet admission criteria according to the length of stay guidelines, then the patient shall be discharged from observation care.

 

R 418.101017   Reimbursement for outpatient minor medical-surgical procedures performed in outpatient hospital setting when billed on UB-92.

Rule 1017. (1) Reimbursement for services listed on Table 10922 shall be made as follows:

(a)     If the service occurs in the first 10 days of care beginning for a work injury, then the hospital shall be reimbursed by the ratio methodology. The ratio methodology shall be used to reimburse the hospital facility for the following services:

Outpatient surgery.

Appropriate emergency room visits.

Inpatient hospitalization or 24-hour outpatient observation stays.

(b)     If the service occurs after the first 10 days, then the carrier shall reimburse the facility for the technical component of the procedure, or 60% of the maximum allowable payment for those minor medical, surgical and radiology procedures.

(2) This rule shall not apply to services performed in a hospital-owned or hospital-system owned occupational or industrial clinics or departments, as those services shall be considered practitioner services and shall be billed and paid as a practitioner service.

 

R 418.101022 Facility reimbursement excluding hospital or freestanding surgical  outpatient facility.

Rule 1022. (1) When the following licensed facilities provide services to an injured worker and bill the carrier, the billed services shall be considered by report:

(a)    Nursing home.

(b)    County medical care facility.

(c)    Hospice.

(d)    Hospital long-term care unit.

(e)    Intermediate care facility or skilled nursing facility.

(2) A licensed facility in subrule (1) of this rule shall be reimbursed by its usual and customary charge or reasonable amount for the service provided, whichever is less. If a carrier does not reimburse the facility within 30 days of receipt of a properly submitted bill, the carrier shall reimburse the facility an additional 3% late fee.

 

 

 

R 418.101023 Reimbursement for a freestanding surgical outpatient facility service.

Rule 1023. (1) Reimbursement for surgical procedures performed in a freestanding surgical outpatient facility shall be determined by using grouper rates as determined by Medicare and published in the Federal Register. The surgical procedures shall be classified into 1 of 9 groupers, numbered 1-9. An allowable rate is assigned to each grouper and the payment is determined by multiplying the grouper rate times a wage index. The rates for the groupers shall be published by the agency in the Health Care Services Manual. The wage index shall be determined by the workers’ compensation agency and shall be published in the Health Care Services Manual.

(2)   The state of Michigan workers’ compensation health care services rules shall adopt the payment system described in subrule 1 of this rule adding 80% to the rate reflecting a payment that is 80% higher than Medicare. The geographical wage-index used to calculate the payment for the surgical procedures shall be 1.0147, representing urban Michigan. The formula for determining the maximum allowable payment (MAP) for a surgical procedure performed in a freestanding surgical outpatient facility shall be as follows: (grouper rate) x (1.8) x (wage-index of 1.0147).

(3)    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 may not un- bundle surgical procedure codes when billing the services.

(4)   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.

(5)   When an item is implanted during the surgical procedure and the freestanding surgical outpatient facility bills the implant and includes the copy of the invoice, the implant shall be reimbursed at the cost of the implant plus a percent mark-up as follows:

(a)    Cost of implant: $1.00-$500.00 shall receive cost + 50%.

(b)    Cost of implant: $500.01-$1000.00 shall receive cost + 30%.

(c)    Cost of implant: $1000.01 and higher shall receive cost + 25%.

(6)   Laboratory services shall be reimbursed by the maximum allowable payment as determined in R 418.101503.

(7)   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 postoperative radiology services may be globally billed.

(8)   When the freestanding surgical facility provides durable medical equipment, the items shall be reimbursed in accord with R 418.101003 (5).

 

PART 11. HOSPITAL PAYMENT RATIO

 

R 418.101101 Calculation and revision of payment ratio for Michigan hospitals.

Rule 1101. (1) The workers' compensation agency shall annually calculate and revise, under the provisions of 1969 PA 306, 24.201 et seq. MCL, the payment ratios for all Michigan hospitals. The calculation shall be made using a hospital’s most recent fiscal year information that is submitted to the Michigan department of community health, medical services administration, preceding each annual calculation. The information used shall be that reported to the Michigan department of community health, medical services administration, on the hospital’s statement of patient revenues and operating

 

 

expenses, G2 worksheet. The workers' compensation agency shall complete the payment ratio calculation between September 1 and October 1, or the earliest date when the figures are available from Michigan department of community health and shall annually publish the hospital ratio calculations in a separate manual effective for dates of service on or after the effective date of these rules.

(2) The workers' compensation agency shall calculate a hospital’s cost-to-charge ratio by dividing each hospital’s total operating expenses by total patient revenues as reported on the hospital’s statement of patient revenues and operating expenses, G2 worksheet.

 

R 418.101102 Calculation and revision of payment ratio for hospitals outside Michigan.

Rule 1102. The workers’ compensation agency shall annually calculate and revise, under the provisions of 1969 PA 306, as amended, being §24.201 et seq. of the MCL, at the same time as calculating Michigan hospitals’ payment ratios, a weighted state average payment ratio to be used for hospitals that are located outside the state of Michigan. The payment ratio shall be calculated by dividing the total hospital operating expenses for Michigan by the total hospital patient revenues for Michigan as reported under R 418.1101(1).

 

R 418.101103 Adjustments to hospital’s payment ratio.

Rule 1103. (1) A hospital may apply to the agency for an adjustment of the hospital’s maximum payment ratio.

(2)   The hospital shall apply for an adjustment on a form and in a manner prescribed by the workers’ compensation agency.

(3)    If the agency determines that a hospital’s ratio of total operating expenses to total patient revenues, as reported on the hospital’s statement of patient revenues and operating expenses, G2 worksheet, for a hospital’s most recent fiscal year is higher than the payment ratio calculated according to R 418.1101, so that the amount of underpayment is more than $100,000.00 or is equal to or greater than 2/10 of 1% of the hospital’s operating expenses for the year, then the agency shall revise the payment ratio and shall notify the hospital and all carriers of the revised payment ratio within 45 days after the receipt of a properly submitted request for an adjustment.

(4)   If a hospital’s request for an adjustment to the hospital’s payment ratio is denied by the workers’ compensation agency, then a hospital may request reconsideration and appeal of the agency’s action regarding the hospital’s request for adjustment of its payment ratio.

 

R 418.101104 Request for adjustment to hospital’s maximum payment ratio; agency’s response.

(2) The workers’ compensation agency shall also furnish the hospital with an appeal form. The appeal form shall include an explanation of the appeal process.

 

R 418.101105  Agency’s action on request for adjustment of maximum payment ratio; hospital’s appeal.

Rule 1105. (1) If a hospital is in disagreement with the action taken by the workers’ compensation agency on its request for adjustment of the hospital’s maximum payment ratio, then a hospital may, within 30 days of receipt of the agency’s action on the hospital’s request for adjustment to its maximum payment ratio, deliver or mail an appeal of the agency’s action to the agency. The appeal shall include a

 

 

detailed statement of the reasons for disagreement and shall request reconsideration of the agency’s action on the hospital’s request for adjustment.

(2) The workers’ compensation agency shall hold a hearing within 30 days of the receipt of a hospital’s appeal under section 847 of the act.

 

PART 12. CARRIER’S HEALTH CARE REVIEW PROGRAM

 

 

R 418.101204 Carrier’s professional health care review program.

Rule 1204. (1) A carrier may have another entity perform professional health care review activities on its behalf.

(2)    The workers’ compensation agency shall certify a carrier’s professional health care review program pursuant to R 418.101206.

(3)   The carrier shall submit a completed form entitled “Application for Certification of the Carrier’s Professional Health Care Review Program” to the agency. If the carrier is a self-insured employer or self-insured group fund, then the service company information shall be included on the form in addition to the carrier and review company information. In addition to the completed form, the carrier shall submit all of the following:

(a)    The methodology used to perform professional review.

(b)     A listing of the licensed, registered, or certified health care professionals reviewing the health care bills or establishing guidelines for technical review. In addition, the proof of current licensure and qualifications for the health care professionals shall be included with the completed application.

(c)    A list of the carrier’s peer review staff, including specialty.

(4)    The workers’ compensation carrier as defined by these rules maintains full responsibility for compliance with these rules.

(5)   The carrier shall determine medical appropriateness for the services provided in connection with the treatment of a covered injury or illness, using published, appropriate standard medical practices and resource documents. Utilization review shall be performed using 1 or both of the following approaches:

(a)    Review by licensed, registered, or certified health care professionals.

(b)     The application by others of criteria developed by licensed, registered, or certified health care professionals.

(6)   The licensed, registered, or certified health care professionals shall be involved in determining the carrier’s response to a request by a provider for reconsideration of its bill.

(7)    The licensed, registered, or certified health care professionals shall have suitable occupational injury or disease expertise, or both, to render an informed clinical judgment on the medical appropriateness of the services provided.

(8)   When peer review is utilized, a health care professional of the same specialty type as the provider of the medical service shall perform the review.

 

R 418.101205 Scope of professional health care review.

Rule 1205. (1) The carrier, or it’s review company, shall review case records and health-service bills, or both, under the professional health care review program as follows:

(a)    A case where health care service payments, excluding inpatient hospital care, exceed $20,000.00.

(b)    A case involving inpatient hospital care.

(2) The carrier or other entity may at any time review any case record or bill which the carrier or the other entity believes may involve inappropriate, insufficient, or excessive care.

 

 

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. The carrier shall submit a copy of “The Carriers Explanation of Benefits” form utilized to notify providers of payment decisions.

(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, and to the service company and review company when appropriate.

 

R 418.101207 Types of certification.

Rule 1207. (1) Certification shall be either unconditional or conditional.

(2)  The workers’ compensation agency shall issue unconditional certification for a period of 3 years.

(3)   The agency may issue conditional certification if it is determined that the carrier or other entity does not fully satisfy the criteria in R 418.101206(3). If the carrier or other entity agrees to undertake corrective action, then conditional certification shall be granted by the agency for a maximum period of 1 year.

(a)    If the workers’ compensation agency receives multiple written complaints regarding a carrier, or the carrier’s review process, and the agency determines the complaints are valid, or that the carrier has not processed payment for medical services in accord with these rules, then the agency may issue conditional certification.

(4)   The workers’ compensation agency may at any time modify an unconditional certification to a conditional certification if the agency determines that the carrier or other entity fails to satisfy the criteria set forth in R 418.101206(3).

(5)   The carrier shall have the right to appeal the certification decisions under the procedures in these rules.

 

R 418.101208 Renewal of certification.

Rule 1208. (1) A carrier or other entity shall apply to the workers’ compensation agency for renewal of certification in the manner prescribed by the agency, submitting the application 6 months prior to the expiration date on the certification.

(2) A carrier or other entity shall receive renewal of certification upon receipt of an updated description of its program as specified in R 418.101206.

 

R 418.101209 Carrier’s request for reconsideration of professional review certification.

Rule 1209. (1) Within 30 days of the agency’s denial of a carrier’s request for professional review program certification, the agency shall notify the carrier of the reasons for denial of the certification and shall notify the carrier of its right to request reconsideration of the denial providing additional information.

(2) A carrier shall notify the agency, within 30 days of receipt of the professional review program certification denial, of its disagreement with the action of the agency. The carrier’s notice to the agency of disagreement with the agency’s denial shall include a detailed statement of the reasons for the disagreement and shall request reconsideration.

 

 

R 418.101210  Carrier’s request for reconsideration of professional review program certification; response.

Rule 1210. (1) Within 30 days of receipt of a carrier’s request for reconsideration of professional review program certification, the workers’ compensation agency shall notify the carrier of the actions taken and shall furnish a detailed statement of the reasons for the action taken.

(2)    The agency shall furnish the carrier with an appeal form. The appeal form shall include an explanation of the appeal process.

(3)     If a carrier is in disagreement with the action taken by the agency on its request for reconsideration, then a carrier shall deliver or mail its appeal to the agency.

(4)    The workers’ compensation agency shall hold a hearing within 30 days of the receipt of a carrier’s appeal of the agency’s decision regarding certification of the carrier’s professional review program under section 847 of the act.

 

PART 13. PROCESS FOR RESOLVING DIFFERENCES BETWEEN CARRIER AND PROVIDER REGARDING BILL

 

R 418.101301 Carrier’s adjustment or rejection of properly submitted bill.

Rule 1301. (1) If a carrier adjusts or rejects a bill or a portion of the bill, then the carrier shall notify the provider within 30 days of the receipt of the bill of the reasons for adjusting or rejecting the bill or a portion of the bill and shall notify the provider of its right to provide additional information and to request reconsideration of the carrier’s action. The carrier shall set forth the specific reasons for adjusting or rejecting a bill or a portion of the bill and request specific information on a form, “Carrier’s Explanation of Benefits,” prepared by the agency pursuant to the reimbursement section of these rules.

(2)   If the provider sends a properly submitted bill to a carrier and the carrier does not respond within 30 days, and if a provider sends a second properly submitted bill and does not receive a response within 60 days from the date the provider supplied the first properly submitted bill, then the provider may file an application with the agency for mediation or hearing. The provider shall send a completed form entitled “Application for Mediation and Hearing” to the agency and shall send a copy of this form to the carrier.

(3)    The carrier shall notify the employee and the provider that the rules prohibit a provider from billing an employee for any amount for health care services provided for the treatment of a covered work-related injury or illness if that amount is disputed by the carrier under its utilization review program or if the amount is more than the maximum allowable payment established by these rules. The carrier shall request the employee to notify the carrier if the provider bills the employee.

 

R 418.101303  Provider’s request for reconsideration of bill; carrier’s response to provider’s right to appeal.

Rule 1303. (1) Within 30 days of receipt of a provider’s request for reconsideration, the carrier shall notify the provider of the actions taken and provide a detailed statement of the reasons. The carrier’s notification shall include an explanation of the appeal process provided under these rules, including the fact that any requested administrative appeal hearing shall be conducted by a magistrate of the department of labor & economic growth.

(2)     If a provider disagrees with  the action taken by the carrier on the provider’s request for reconsideration, then a provider may file an application for mediation or hearing with the department of labor & economic growth. A provider shall send its application for mediation or hearing to the agency within 30 days from the date of receipt of a carrier’s denial of the provider’s request for reconsideration. The provider shall send a copy of the application to the carrier.

 

 

(3)    If, within 60 days of the provider’s request for reconsideration, the provider does not receive payment for the adjusted or rejected bill or a portion of the bill, or a written detailed statement of the reasons for the actions taken by the carrier, then the provider may apply for mediation or hearing. The provider shall send the application for mediation or hearing to the agency and shall send a copy to the carrier.

 

R 418.101304 Disputes.

Rule 1304. (1) If a carrier adjusts or rejects a bill or a portion of a bill under these rules, then a notice given under R 418.101301(1) creates an ongoing dispute for the purpose of section 801 of the act. The time for making payment of a bill under section 801 of the act shall not run unless the bill is properly submitted according to applicable rules and statutes.

(2)     Any dispute that concerns any of the following shall be resolved as if an application for mediation or hearing was filed under section 847 of the act:

(a)    The medical appropriateness of health care or a health care service.

(b)    Utilization of health care or a health care service.

(c)    The need for health care or a health care service.

(d)    Any dispute over the cost of health care or a health care service.

(3)   If the dispute results in the denial of medical treatment for a worker, or if there is a petition by an employer to stop the employer’s liability for medical benefits previously ordered, including proceedings under subrule (6) of this rule, then the dispute shall receive the same expedited treatment accorded to 60-day cases under section 205 of the act, except that the agency may refer the matter to mediation under section 223 of the act.

(4)   A dispute under this rule may be submitted to arbitration under section 864 of the act.

(5)   A dispute under this rule may be handled as a small claim under section 841(2) to (10) of the act if it meets the requirements of that section.

(6)   If a carrier is required by the terms of an award to provide medical benefits, then the carrier shall continue to provide those benefits until there is a different order by any of the following entities:

(a)    A magistrate.

(b)    The appellate commission.

(c)    The court of appeals.

(d)    The supreme court.

This subrule shall not preclude the use of the maximum allowable payments provided by these rules for the payment of bills by carriers. If a carrier files an application to stop or limit its liability under this subrule, the carrier shall receive the expedited treatment provided for under subrule (3) of this rule.

(7)   If the agency believes that a provider is not in compliance with these rules, then the agency may file an application for mediation or hearing under this rule.

 

R 418.101305  Resolution of disputes.

Rule 1305. (1) If a carrier adjusts a fee or rejects a bill under these rules, then a notice given pursuant to R 418.101301 creates a continuing dispute for the purpose of section 801 of the act. The time for making payment of a bill under section 801 of the act shall not run unless the bill is properly submitted according to applicable rules and statutes.

(2)   A magistrate, as provided under sections 315 and 847 of the act and

R 408.34 and R 408.35, shall resolve any dispute that concerns any of the following:

(a)    The medical appropriateness of health care or a health care service.

(b)    Utilization of health care or a health care service.

(c)    The need for health care or a health care service.

 

 

(d)    Any dispute over the cost of health care or a health care service.

(3)    The agency may participate in any hearings that concern disputes when there is an issue that affects the provisions of these rules regarding maximum fees, medical appropriateness, or utilization of health care or health care services.

 

PART 14. DATA ACQUISITION

 

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 carrier’s total number of worker’s compensation cases and the total medical payments for health care services for those 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.

 

R 418.101402 Access to workers’ compensation case records.

Rule 1402. (1) The workers’ compensation agency shall have access to necessary workers’ compensation health care records, medical bills, and other information concerning health care or health service from workers’ compensation carriers or providers.

(2)   The agency may review the records and medical bills of any provider determined by a carrier to not be in compliance with the rules or to be requiring unjustified treatment, hospitalization, or office visits. If a carrier requests the agency to perform an on-site review of specific records and medical bills of a provider, then the agency shall arrange a mutually acceptable visit date with the provider, by telephone or in writing, at least 15 working days before the visit. The agency shall confirm the date of the visit in writing not less than 10 working days in advance. The agency shall, by that time, identify for the provider the records, which the agency wishes to review. The records shall remain at the provider’s place of business.

(3)    The workers’ compensation agency shall ensure confidentiality of the individual case records regarding health care services provided to any individual.

 

R 418.101404 Access to carrier data for payment of medical claims.

Rule 1404. (1) The workers’ compensation agency shall have access to payment data from the carrier in the form of the carrier’s explanation of benefits and medical bills for the purposes of data analysis.

(2)   A carrier shall be notified by the agency when information is to be submitted not less than 60 days before the date required.

(3)   The agency shall ensure confidentiality of the billing records provided by the selected carriers.

 

 

PART 15. PROCEDURE CODE AND REIMBURSEMENT TABLES

 

R 418.101501    Tables for health care services and procedures.

Rule 1501. (1) Procedures that do not have relative values assigned are referenced in part 15 of these rules and have assigned fees developed by the workers’ compensation agency through rule promulgation and shall be published as part of these rules.

(2)   The agency shall publish separate from these rules a manual containing all of the following:

(a)    Procedure codes and relative value units for the medical, surgical, and radiology services.

(b)      Reference to the ancillary  services identified  in  Medicare's  Level  II  codes  as  adopted  by reference in R 418.10107.

(c)    Maximum payment ratios for hospitals.

(d)    A copy of the billing forms and instructions for completion.

 

R 418.101502  Miscellaneous medical and surgical procedures.

Rule 1502. The medical and surgical procedures without assigned relative values or specific payment methodologies are listed in the following table:

 

99000         Handling or conveyance of specimen ................................................................ $5.00

99050         After hour office service Monday-Friday (R 418.10202).................................. $5.00 99052         Services between 10:00pm and 8:00am ............................................................ $5.00

99054         Weekend, holiday after hour office service ..................................................... $12.00

99199         Carrier arranged missed appointment. (R 418.10111)...................................... BR

99199-32    Carrier or requested report, per page (R 418.10114)....................................... $25.00

WC700        Prescription drug dispense fee (R 418.10912(4) .............................................. $4.00

99455-32    Carrier requested visit for job evaluation (R 418.10404) ................................ $70.00

RN001-32  Rehabilitation or case manager visit (R 418.10121)........................................ $25.00

 

R 418.101503 Laboratory procedure codes and maximum allowable payments.

Rule 1503. (1) The workers’ compensation agency shall determine the maximum allowable payment for the laboratory procedure codes,80048-89356 published in “Physicians’ Current Procedural Terminology (CPT®)as adopted by reference in R 418.10107. The rate shall be determined by multiplying the Medicare rate established for the state of Michigan by 110%.

(2)   The pathology procedure codes found in the 80000 series of procedure codes listed in CPT® as adopted by reference in R 418.10107 have assigned relative values and shall be published by the agency in a separate manual.

(3)     The maximum allowable payments for the laboratory and pathology procedures shall be published the Health Care Services Manual separate from these rules.