-
ORR # 2002-052
DEPARTMENT OF CONSUMER AND INDUSTRY SERVICES BUREAU OF WORKERS’ AND UNEMPLOYMENT COMPENSATION WORKER’S COMPENSATION HEALTH CARE SERVICES
Filed with the Secretary of State on February 24, 2003.
These rules take effect 7 days after filing with the Secretary of State
(By authority conferred on the bureau of worker’s and unemployment compensation by sections 205 and 315 of 1969 PA and Executive Reorganization Nos. 1982-2, 1986-3, 1990-1, 1996-2, 1997-12, and
2002-1, MCL 418.205, 418.315, 24.233, 18.24, 418.1, and 418.2, 445.2001, 421.94, and 445.2004)
R 418.10104, R 418.10105, R 418.10106, R 418.10107, R 418.10108, R 418.10116, R 418.10117, R
418.10121, R 418.10202, R 418.10904, R 418.10915, R 418.10916, R 418.10922, R 418.10923,
R 418.10925, R 418.101002, R 418.101204, R 418.101206,and R 418.101501 of the Michigan
Administrative Code are amended, R 418.10902, R 418.101502, R 418.101503, and R 418,101504 are added to the Code, and R 418.10924 of the code is rescinded as follows:
R 418.10104 Reimbursement to an injured worker or to a 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 shall not be required to 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 HCFA 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 providers’ 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 418.10105 Balance billing amounts in excess of fees.
Rule 105. The provider shall not bill the injured worker for any amount for health care services, or for late fees incurred, provided for the treatment of a covered injury or illness when the amount is disputed
by the carrier pursuant to its utilization review program or when the amount exceeds the maximum allowable payment established by these rules.
R 418.10106 Procedure codes; relative value units; and other billing information.
Rule 106. (1) Upon annual promulgation of R 418.10107, the health care services division of the bureau shall publish a manual separate from these rules containing all of the following information:
(a) All CPT® procedure codes used for billing health care services.
(b) Medicine, surgery, and radiology procedures and their associated relative value units.
(c) Hospital maximum payment ratios.
(d) Billing forms and instruction for completion.
(2) The procedure codes and standard billing instructions for medicine, surgery, and radiology services shall be adopted from the most recent publication entitled “Physicians’ Current Procedural Terminology, (CPT®)” as adopted by reference in R 418.10107.
(3) The formula and methodology for determining the relative value units shall be adopted from the “Medicare RBRVS Fee Schedule” as adopted by reference in R 418.10107 using geographical information for Michigan. The geographical information, (GPCI), for these rules is a melded average using 60% of the figures published for Detroit added to 40% of the figures published for the rest of the state.
(4) The maximum allowable payment for medicine, surgery, and radiology services shall be determined by multiplying the relative value unit assigned to the procedure times the conversion factor listed in the reimbursement section, part 10 of these rules.
(5) Procedure codes from “Medicare’s National Level II Codes HCPCS” as adopted by reference in 418.10107 shall be used to describe all of the following services:
(a) Ambulance services.
(b) Medical and surgical expendable supplies.
(c) Dental procedures.
(d) Durable medical equipment.
(e) Vision and hearing services.
(f) Home health services.
(6) The following medical services shall be considered “By Report” (BR):
(a) All ancillary services listed in “Medicare’s National Level II Codes HCPCS”, referenced in R 418.10106.
(b) All CPT® procedure codes that do not have an assigned relative value.
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 bureau of workers' and unemployment compensation, health care services division, P.O. Box 30016, Lansing, Michigan 48909, at the costs listed or from the organizations listed:
(a) "Physicians’ Current Procedural Terminology (CPT®) 2003," standard edition, copyright October 2002, published by the American Medical Association, PO Box 930876, Atlanta GA, 31193-0876, order
#OP054103BTF, 1-800-621-8335. The publication may be purchased at a cost of $54.95 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 bureau.(b) "Medicare's National Level II Codes, HCPCS, 2003," copyright November 2002, published by the American Medical Association, P.O. Box 930876 Atlanta GA 31193-0876, order # OP095103BTF,
customer service 1-800-621-8335. The publication may be purchased at a cost of $84.95, plus $11.95 for shipping and handling as of the time of adoption of these rules.
(c) “Medicare RBRVS 2002: The Physicians’ Guide,” published by The American Medical Association, 515 North State Street, Chicago Il, 60610, order #OPO59602BLC, 1-800-621-8335. The publication may be purchased at a cost of $74.95,plus $8.95 shipping and handling as of the time of adoption of these rules.
(d) “Medicare RBRVS 2003: 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
(e) "International Classification of Diseases, ICD-9-CM 2003" copyright 2002, American Medical Association, P.O. Box 930876, Atlanta GA 31193-0876, order
#OP065103BTF, 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.(f) "2002 Drug Topics Red Book," published by Medical Economics Company Inc., Five Paragon Drive, Montvale, NJ 07645-1742, 1-800-678-5689. The publication may be purchased at a cost of $64.95, plus $7.95 for shipping and handling as of the time of adoption of these rules.
(g) "Michigan Uniform Billing Manual," developed in cooperation with the American Hospital Association's National Uniform Billing Committee, published by Michigan Health and Hospital Association, 6215 West St.Joseph Highway, Lansing, MI 48917, 517-886-8366. As of the time of adoption of these rules, the cost of the publication is $160.00, plus 6% sales tax.
(h) “Relative Value Guide: A Guide For Anesthesia Values 2002,” published by the American Society of Anesthesiologists, 520 N Northwest Highway, Park Ridge, IL 60068-2573, 1-847-825-5586. As of the time of adoption of these rules, the cost of the publication, including shipping is $15.00.
R 418.10108 Definitions; A to I.
Rule 108. As used in these rules:
(a) “Act” means 1969 PA 317, MCL 418.101 et seq.
(b) “Adjust” means that a carrier or a carrier’s agent reduces a health care provider’s request for payment to the maximum fee allowed by these rules, to a provider’s usual and customary charge, or, when the maximum fee is by report, to a reasonable amount. Adjust also means when a carrier re-codes a procedure, or reduces payment as a result of professional review.
(c) “Appropriate care” means health care that is suitable for a particular person, condition, occasion, or place.
(d) “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.
(e) “Bureau” means the bureau of workers’ disability compensation in the department of consumer and industry services.
(f) “Carrier” means an organization which transacts the business of workers’ disability 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) A health maintenance organization.
(ii) An industrial or other clinic.
(iii) An occupational health care center.
(iv) A home health agency.
(v) A visiting nurse association.
(vi) A laboratory.
(vii) A medical supply company.
(viii) A 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 418.10116 Provider responsibilities.
Rule 116. (1) When a licensed facility or practitioner licensed in this state treats an injured worker for a compensable work-related injury or illness and bills the workers’ compensation carrier, the carrier shall reimburse the licensed provider or facility the maximum allowable payment, or the providers’ usual and customary charge, whichever is less, in accord with these rules. A provider shall do both of the following:
(a) Promptly bill the carrier or the carrier’s designated agent after the date of service.
(b) Submit the bill for the medical services provided to treat an injured worker on the proper claim form, to the workers’ compensation carrier or the carrier’s designated agent and attach the documentation required in part 9 of these rules.
(2) If the provider has not received payment within 30 days of submitting a bill, then the provider shall resubmit the bill to the carrier and add a 3% late fee.
R 418.10117 Carrier responsibilities.
Rule 117. (1) The carrier or its designated agent shall assure that a billing form is completed properly before making payment 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 bureau. 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 a case is disputed by the carrier, and when the carrier 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 notifying the provider of non-payment of the bill due to the dispute.
R 418.10121 Rehabilitation nurse or nurse case manager visits; additional services.
Rule 121. (1) If a carrier assigns a rehabilitation nurse or nurse case manager to an injured worker’s case, and the carrier requires that the nurse accompany the injured worker to provider visits, then the carrier shall reimburse the provider for the additional time.
(2) The provider may bill the rehabilitation nurse or nurse case manager visit in addition to the evaluation and management service using code RN001. The carrier shall reimburse the provider $25.00 for RN001.
(3) Procedure code RN001 shall be reimbursed at the maximum allowable fee if the provider bills the procedure during the global period for a surgical service.
R 418.10202 Evaluation and management services.
Rule 202. (1) Procedure code 97010 performed in conjunction with an evaluation and management office visit shall not be reimbursed as a separate procedure.
(2) Minor medical and surgical supplies routinely used by the practitioner or health care organization in the office visit shall not be billed separately.
(3) Supplies or other services over and above those usually incidental to an office visit or other outpatient visit for the evaluation and management of a patient shall be billed separately under procedure code 99070.
(4) If an office visit is performed outside of the provider’s normal business hours, the provider may bill the add on procedure codes describing an office visit performed after hours or on Sundays or holidays. A provider may bill add on procedure code 99050 in addition to the evaluation and management service, if a service is rendered between the hours of 6 p.m. and 7 a.m., Monday through Saturday. A provider may bill add on procedure code 99054 if a service is rendered on Sundays or holidays until 7 a.m. of the following regular working day.
(5) A procedure that is normally part of an examination or evaluation shall not be billed independently. Range of motion shall not be reimbursed as a separate procedure in addition to the evaluation and management service unless the procedure is medically necessary and appropriate for the injured worker’s condition and diagnosis.
(6) The maximum allowable payment for the evaluation and management service shall be determined by multiplying the relative value unit, RVU, assigned to the procedure code, times the conversion factor listed in the reimbursement section of these rules.
(7) The level of an office visit or other outpatient visit for the evaluation and management of a patient is not guaranteed and may change from session to session. The level of service shall be consistent with the type of presenting complaint and supported by documentation in the record.
(8) Procedure codes 99455 and 99456 describing work-related or medical disability evaluation services shall not be used to describe an evaluation and management service for treating a work-related injury or illness. Procedure codes 99201-99350 shall be used to describe the practitioner’s medical treatment of an injured worker.
(9) The carrier shall not reimburse the provider for procedure codes 90782-90799, administration of therapeutic injections, if billed in conjunction with an evaluation and management service. The medication administered in the therapeutic injection shall be billed using procedure code 99070 or the appropriate J-code from Medicare’s National Level II Codes, as adopted by reference in R 418.10107,and shall be identified with the national drug code number. The provider shall be reimbursed at the average wholesale price of the drug. If the provider does not bill an evaluation and management service, then the appropriate procedure code describing the administration of the drug may be billed. The administered drug is billed additionally and is payable at the average wholesale price of the drug.
(10) The provider may bill immunization procedure codes in addition to the evaluation and management procedure code. If the provider bills an immunization, then the vaccine is described with procedure
codes 90476-90748, and the administration of the vaccine is described with procedure code 90471 or 90472. The carrier shall reimburse the vaccine at the average wholesale price of the vaccine plus the cost of administration billed with procedure code 90471 or 90472.
R 418.10902 Billing for injectable medications, other than vaccines and toxoids, in the 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 HCFA 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 bureau. 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
-SA When an anesthesiologist supervises, or provides medical direction to, a certified registered nurse anesthetist or anesthesiology resident.
-AA When an anesthesiologist bills for services performed by the anesthesiologist.
-AH When a licensed psychologist bills a diagnostic service or a therapeutic service, or both.
-AJ When a certified social worker bills a therapeutic service.
-AK When a nurse who has a specialty certification, as defined in these rules, treats an injured worker and bills a service other than assistant at surgery.
-AL A limited license psychologist billing a diagnostic service or a therapeutic service.
-AU When a physician’s assistant treats an injured worker for a medical service other than an assistant at surgery.
-CS When a limited licensed counselor bills for a therapeutic service.
-LC When a licensed professional counselor performs a therapeutic service.
-MF When a licensed marriage and family therapist performs a therapeutic service.
-ML When a limited licensed marriage and family therapist performs a service.
-TC When billing for the technical component of a radiology service.
-QX When a certified registered nurse anesthetist performs a service under the medical direction of an anesthesiologist.
-QZ When a certified registered nurse anesthetist performs anesthesia services without medical direction.
R 418.10915 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 “The Relative Value Guide, A Guide For Anesthesia Values,” as adopted by reference in R 418.10107. The anesthesia codes and base units shall be published separate from these rules by the bureau.
(2) The anesthesia base units shall include all of the following:
(a) The pre-anesthesia evaluation.
(b) Preparation.
(c) Post-anesthesia care.
(3) Anesthesia time shall begin when the provider physically starts to prepare the patient for induction of anesthesia in the operating room and shall end when the provider is no longer in constant attendance. The total time in minutes shall be listed in the days or units column of the HCFA 1500 claim form.
(4) 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 HCFA 1500 with the appropriate modifier on each line.
(5) 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 -SA indicates the anesthesiologist has supervised a certified registered nurse anesthetist who is employed by either a hospital, the anesthesiologist or is self-employed.
(c) Modifier -QX indicates the certified registered nurse anesthetist has administered the procedure under the 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.
(6) Total anesthesia units shall be calculated by adding the anesthesia base units to the anesthesia time units.
(7) 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.
(8) If a surgeon provides the anesthesia service, the surgeon will only be reimbursed the base units for the anesthesia procedure.
(9) 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:
P1
Anesthesiology Physical Status Modifiers
A normal healthy patient.
Unit Value
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 purposes.
0
(10) 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.
(11) 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.
R 418.10916 Billing for minor practitioner services performed in an outpatient hospital setting. Rule 916. (1) This rule applies to the practitioner component of minor procedures that can safely be performed in a setting other than an outpatient hospital. If a practitioner or health care organization submits a bill for a procedure code listed in table 10916 in the outpatient hospital setting, then modifier code -26 shall be added to the procedure code and the carrier shall pay the maximum allowable fee listed in the manual for the professional portion of the procedure, or, if the professional portion is not listed, then the carrier shall pay 40% of the maximum allowable fee for the procedure.
(2) This rule shall not apply to any of the following instances:
(a) During an inpatient, observation stay, or services appropriately performed in the emergency room department.
(b) For procedures performed during an outpatient surgery.
(c) If procedures from table 10916 are performed during the course of an outpatient setting in conjunction with a procedure that is appropriately performed in the outpatient setting; for example, a radiology procedure with a myelogram or outpatient surgery.
(3) This rule shall not apply if the procedure is performed by an emergency room physician granted privileges by the hospital to practice in the emergency room.
(4) Table 10916 reads as follows:
TABLE 10916
10060
20665-20670
30901
65205-65222
92531-92599
10120
23065
40800
67700
93740
10140
23330
40804
67715-67805
94010-95065
10160
24065
40820
67810-67825
95115-95199
11000
24200
41000-41005
67938
95180
11040
25065
41800-41805
69000
95860-95904
11100-11101
26010
42300
69020
95930-95937
11720-11750
27040
42310
70030-70360
98925-98943
11900-11901
27086
45300
70450-71030
99195
12001-12004
27323
45330
71100-72220
99201-99215
15860
27613
46050
73000-74420
99241-99245
16000
28001
50398
74400-74420
90801-90815
16020-16030
28190
51000
78300-78699
20500
30000-30100
51700-51710
90901-90911
20520
30200-30210
53600-53661
92002-92014
20550-20610
30300
53670-53675
92230-92504
R 418.10922 Hospital billing instructions.
Rule 922. (1) A hospital billing for the facility portion of emergency department, outpatient, and inpatient services, shall bill facility charges on the UB-92 national uniform billing claim form and shall include revenue codes, ICD.9.CM coding, and CPT® codes for surgical, radiological, laboratory, medicine, and evaluation and management services.
(2) Procedures listed in Table 10922 can safely be performed in an outpatient setting other than an outpatient hospital. When procedures listed in Table 10922 are performed in the outpatient hospital setting, the carrier shall pay the maximum allowable fee listed in the manual for the technical component of the procedure, or 60% of the maximum allowable fee if the technical component is not listed. This rule does not apply to any of the following:
(a) During the first 10 days of care commencing for an injury.
(b) During an inpatient or observation stay or services appropriately performed in the emergency room department.
(c) Procedures performed during the time of an outpatient surgery.
(d) If a procedure included in Table 10922 is combined with another procedure not found on Table 10922; for example, a radiology procedure with a myelogram or outpatient surgery.
(3) Table 10922 reads as follows:
TABLE 10922
10060
20665-20670
30901
65205-65222
92531-92599
10120
23065
40800
67700
93740
10140
23330
40804
67715-67805
94010-95065
10160
24065
40820
67810-67825
95115-95199
11000
24200
41000-41005
67938
95180
11040
25065
41800-41805
69000
95860-95904
11100-11101
26010
42300
69020
95930-95937
11720-11750
27040
42310
70030-70360
98925-98943
11900-11901
27086
45300
70450-71030
99195
12001-12004
27323
45330
71100-72220
99201-99215
15860
27613
46050
73000-74020
99241-99245
16000
28001
50398
74400-74420
90801-90815
16020-16030
28190
51000
78300-78699
20500
30000-30100
51700-51710
90901-90911
20520
30200-30210
53600-53661
92002-92014
20550-20610
30300
53670-53675
92230-92504
(4) If a hospital clinic, other than an industrial or occupational medicine clinic, bills under a hospital’s federal employer identification number, then a hospital clinic facility service shall be identified by using revenue code 510 “clinic.”
(5) A hospital shall bill the physical, occupational, and speech therapy services on the UB-92 national uniform billing claim form and the hospital shall be paid according to the hospital’s payment ratio. The hospital shall provide the carrier with the initial evaluation and progress notes every 30 days.
(6) A hospital system-owned office practice shall not bill facility fees
(7) A hospital or hospital system-owned industrial or occupational clinic providing occupational health services shall not bill facility fees.
R 418.10923 Hospital billing for practitioner services.
Rule 923. (1) A hospital billing for practitioner services, including a certified registered nurse anesthetist, a physician, a nurse who has a specialty certification, and a physician’s assistant, shall submit bills on a HCFA 1500 form and the hospital shall use the appropriate procedure codes adopted by these rules. A hospital shall bill for professional services provided in the hospital clinic setting as practitioner services on a HCFA 1500 form using site of service 2 or 22. A hospital or hospital system- owned office practice shall bill all office services as practitioner services on a HCFA 1500 form using site of service 3 or 11. 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 HCFA 1500 using site of service 3 or 11. 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 medicine service, excluding physical medicine, occupational medicine, or speech therapy, evaluation and management or surgical service using site of service 2 or 22 shall bill the service on a HCFA 1500 claim form and add 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.
(3) A hospital billing for a radiologist’s or pathologist’s services shall bill the professional component of the procedure on the HCFA 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 418.10924 RESCINDED.
R 418.10925 Billing requirements for facility other than a hospital.
Rule 925. (1) A facility, other than a hospital, that is licensed by the state 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) If billing radiological services or laboratory services, a facility, other than a hospital, that is licensed by the state shall bill only the technical component on the UB-92 national uniform billing claim form.
(3) If a facility, other than a hospital, that is licensed by the state bills for the professional component of a radiological service, the professional component of a laboratory service, physician or physician’s assistant service, or nurse practitioner service, then the service shall be billed on a HCFA 1500 claim form, using the appropriate CPT® procedure code and modifier -26. If billing for a certified nurse anesthetist service, the facility will modify the procedure with modifier QX or QZ.
(4) If billing for services, a facility, other than a hospital, that is licensed by the state shall include a report that describes the services provided and the condition of the patient.
R 418.101002 Conversion factors for medical, surgical, and radiology procedure codes.
Rule 1002. (1) The bureau shall determine the conversion factors for medical, surgical, and radiology procedures. The conversion factor shall be used by the bureau for determining the maximum allowable payment for medical, surgical, and radiology procedures. The maximum allowable payment shall be determined by multiplying the appropriate conversion factor times the relative value unit assigned to a procedure. The relative value units are listed for the medicine, surgical, and radiology procedure codes in a manual separate from these rules. The manual shall be published annually by the bureau using codes adopted from “Physicians’ Current Procedural Terminology (CPT®)” as referenced in R 418.10107(a). The Bureau shall determine the relative values by using information found in the “Medicare RBRVS: The Physicians’” as adopted by reference in R 418.10107(c).
(2) The conversion factor for medicine, radiology, and surgical procedures shall be $47.01 for the year 2003.
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 bureau 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 bureau. 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 418.101206 Certification of professional health care review program.
Rule 1206. (1) The bureau 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 bureau for certification of a carrier’s professional health care review program in the manner prescribed by the bureau.
(3) A carrier shall receive certification if the carrier or the carrier’s review company provides to the bureau a description of its professional health care review program and includes all of the information specified in R 418.101204. The bureau 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.
PART 15 BUREAU DEVELOPED FEE 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 bureau through rule promulgation and shall be published as part of these rules.
(2) The bureau 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
99025 New patient exam with a starred surgical procedure .......................................... $55.00
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 laboratory procedure codes, listed in the table in this rule have maximum allowable payments established by the bureau. All other laboratory procedure codes listed in CPT® as adopted by reference in R 418.10107 shall be paid as a by report procedure.
(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 bureau in a separate manual.
82009 ..................... test for acetone/ketones ......................................................................................$3.30
82010 .................... acetone assay .....................................................................................................$24.20
82042 .................... assay of urine albumin.........................................................................................$3.30
82055 .................... assay of ethanol .................................................................................................$31.00
82075 .................... assay of breath ethanol ......................................................................................$35.00
82140 .................... assay of ammonia ................................................................................................$9.90
82145 .................... assay of amphetamines........................................................................................$9.90
82150 .................... assay of amylase..................................................................................................$8.80
82175 .................... assay of arsenic .................................................................................................$13.20
82180 .................... assay of ascorbic acid........................................................................................$16.50
82205 .................... assay of barbiturates ..........................................................................................$26.00
82330 .................... assay of calcium ................................................................................................$23.00
82340 .................... assay of calcium in urine ...................................................................................$11.00
82375 .................... assay, blood carbon monoxide ..........................................................................$19.80
82436 .................... assay of urine chloride ........................................................................................$7.70
82482 .................... assay, rbc cholinesterase .....................................................................................$9.90
82486 .................... gas/liquid chromatography ................................................................................$27.00
82487 .................... paper chromatography.........................................................................................$9.63
82488 .................... paper chromatography.........................................................................................$9.63
82489 .................... thin layer chromatography ..................................................................................$9.63
82495 .................... assay of chromium ............................................................................................$16.50
82507 .................... assay of citrate...................................................................................................$13.20
82540 .................... assay of creatine ................................................................................................$19.80
82550 .................... assay of ck (cpk)..................................................................................................$8.00
82552 .................... assay of cpk in blood.........................................................................................$23.25
82553 .................... creatine, mb fraction..........................................................................................$20.90
82600 .................... assay of cyanide ................................................................................................$23.10
82705 .................... fats/lipids, feces, qual ........................................................................................$13.20
82710 .................... fats/lipids, feces, quant ......................................................................................$32.18
82735 .................... assay of fluoride ................................................................................................$16.50
82800 .................... blood ph...............................................................................................................$3.30
82803 .................... blood gases: ph, po2 & pco2 .............................................................................$13.20
82951 .................... glucose tolerance test (gtt).................................................................................$19.00
83015 .................... heavy metal screen ............................................................................................$13.20
83018 .................... quantitative screen, metals ..................................................................................$5.00
83050 .................... blood methemoglobin assay ..............................................................................$19.80
83051 .................... assay of plasma hemoglobin..............................................................................$13.20
83055 .................... blood sulfhemoglobin test .................................................................................$17.60
83060 .................... blood sulfhemoglobin assay ..............................................................................$19.80
83069 .................... assay of urine hemoglobin...................................................................................$3.30
Code Descriptor of laboratory procedure code MAP
83070 .................... assay of hemosiderin, qual ..................................................................................$4.00
83071 .................... assay of hemosiderin, quant ................................................................................$4.13
83540 .................... assay of iron ........................................................................................................$8.00
83550 .................... iron binding test...................................................................................................$9.08
83655 .................... assay of lead ......................................................................................................$16.50
83690 .................... assay of lipase .....................................................................................................$9.90
83715 .................... assay of blood lipoproteins................................................................................$24.20
83718 .................... assay of lipoprotein .............................................................................................$8.25
83719 .................... assay of blood lipoprotein ...................................................................................$8.25
83721 .................... assay of blood lipoprotein ...................................................................................$8.25
83785 .................... assay of manganese ...........................................................................................$16.50
83805 .................... assay of meprobamate .......................................................................................$25.58
83825 .................... assay of mercury................................................................................................$16.50
83885 .................... assay of nickel ...................................................................................................$13.20
83925 .................... assay of opiates ...................................................................................................$5.78
83930 .................... assay of blood osmolality ..................................................................................$13.20
83986 .................... assay of body fluid acidity ..................................................................................$3.30
83992 .................... assay for phencyclidine .....................................................................................$17.60
84078 .................... assay alkaline phosphatase ................................................................................$19.80
84080 .................... assay alkaline phosphatases ..............................................................................$27.50
84106 .................... test for porphobilinogen ......................................................................................$9.90
84110 .................... assay of porphobilinogen ..................................................................................$19.80
84155 .................... assay of protein ...................................................................................................$3.00
84160 .................... assay of serum protein.........................................................................................$4.00
84255 .................... assay of selenium ..............................................................................................$13.20
84300 .................... assay of urine sodium..........................................................................................$7.98
84311 .................... spectrophotometry...............................................................................................$6.88
84315 .................... body fluid specific gravity...................................................................................$3.30
84375 .................... chromatogram assay, sugars................................................................................$9.63
84430 .................... assay of thiocyanate ..........................................................................................$25.58
84478 .................... assay of triglycerides ...........................................................................................$8.00
84540 .................... assay of urine/urea-n ...........................................................................................$7.70
84545 .................... urea-n clearance test ..........................................................................................$12.10
84550 .................... assay of blood/uric acid.....................................................................................$11.00
84600 .................... assay of volatiles ...............................................................................................$22.55
84630 .................... assay of zinc ......................................................................................................$13.20
85007 .................... differential wbc count .........................................................................................$7.00
85008 .................... nondifferential wbc count ...................................................................................$0.83
85009 .................... differential wbc count .........................................................................................$7.98
85013 .................... hematocrit............................................................................................................$2.48
85014 .................... hematocrit............................................................................................................$3.30
85018 .................... hemoglobin..........................................................................................................$8.00
85021 .................... automated hemogram ..........................................................................................$5.50
85022 .................... automated hemogram ........................................................................................$16.00
85027 .................... automated hemogram ..........................................................................................$6.88
85031 .................... manual hemogram, cbc......................................................................................$12.10
85041 .................... red blood cell (rbc) count ....................................................................................$3.30
85170 .................... blood clot retraction ............................................................................................$6.60
85175 .................... blood clot lysis time ..........................................................................................$20.90
85345 .................... coagulation time ..................................................................................................$9.90
85347 .................... coagulation time ..................................................................................................$9.90
85348 .................... coagulation time ..................................................................................................$9.90
85610 .................... prothrombin time.................................................................................................$7.70
85651 .................... rbc sed rate, nonautomated..................................................................................$8.00
85652 .................... rbc sed rate, automated........................................................................................$8.00