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DEPARTMENT OF LABOR & ECONOMIC GROWTH WORKERS’ COMPENSATION AGENCY
WORKERS’ COMPENSATION HEALTH CARE SERVICES
Filed with the Secretary of State on February 21, 2008
These rules become effective 7 days after filing with the Secretary of State.
(By authority conferred on the workers’ compensation agency by sections 205 and 315 of 1969 PA 317, section 33 of 1969 PA 306, Executive Reorganization Order Nos. 1982-2, 1986-3, 1990-1, 1996-2, and
2003-1, MCL 418.205, 418.315, 24.233, 18.24, 418.1, 418.2, 445.2001, and 445.2011)
R 418.10104, R 418.10107, R 418.10504, R 418.10901, R 418.10902, R 418.10909, R 418.10912, R
418.10913, R 418.10921, R 418.10922, R 418.10923, R 418.10923b, R 418.10925, R 418.101002a, R 418.101003, R 418.101005, R 418.101015, R 418.101023 are amended, and R 418.101003a is added
to the Michigan Administrative Code.
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-04 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.
December 3, 2007
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®) 2008," professional edition, copyright October 2007, published by the American Medical Association, PO Box 930884, Atlanta GA, 31193-0884, order
# OP138508DGE, 1-800-621-8335. The publication may be purchased at a cost of $74.95, 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, 2008," copyright December 2007, published by the American Medical Association, P.O. Box 930884 Atlanta GA 31193-0884, order # OP095108, customer service 1-800-621-8335. The publication may be purchased at a cost of $94.95, plus $11.95 for shipping and handling as of the time of adoption of these rules.
(c) “Medicare RBRVS 2007: The Physicians’ Guide,” published by The American Medical Association,
P.O. Box 930876, Atlanta GA 31193-0876, order #OP059606CKF, 1-800-621-8335. The publication may be purchased at a cost of $87.95, plus $11.95 shipping and handling as of the time of adoption of these rules.
(d) “Medicare RBRVS 2008: The Physicians’ Guide,” published by The American
Medical Association, P.O. Box 930884, Atlanta GA 31193-0884, order
#OP059608, 1-800-621-8335. The publication may be purchased at a cost of $89.95, plus $11.95 shipping and handling as of the time of adoption of these rules.(e) "International Classification of Diseases, ICD-9-CM 2008Volumes 1 & 2," copyright September 2007, American Medical Association, P.O. Box 930884, Atlanta GA 31193-0884, order #OP065108, 1- 800-621-8335. The publication may be purchased at a cost of $92.95, plus $11.95 shipping and handling as of the time of adoption of these rules.
(f) "2007 Drug Topics Red Book," published by Thomson PDR, PO Box 6911, Florence, KY 41022- 9700, 1-800-678-5689. The publication may be purchased at a cost of $76.95, plus $9.95 for shipping and handling as of the time of adoption of these rules.
(g) “Official UB-04 Data Specifications Manual 2008 (v. 2.00), July 1, 2007,” developed in cooperation with the American Hospital Association’s National Uniform Billing committee, published by American Hospital Association, National Uniform Billing Committee – UB-04, P.O. Box 92247, Chicago, IL 60675-2247, 1-312-422-3390. As of the time of adoption of these rules, the cost of the publication is
$150.00.
R 418.10504 Multiple procedure policy for radiology procedures performed within families or groups of contiguous body parts.
Rule 504. (1) A multiple procedure payment reduction shall apply to specified radiology procedures when performed in a freestanding radiology office, a non-hospital facility, or a physician’s office or clinic. The primary procedure, identified by the code with the highest relative value, shall be paid at 100% of the maximum allowable payment. If the provider’s charge is less than the maximum allowable payment, then the service shall be paid at 100% of the provider’s charge.
(2) The multiple payment reduction policy shall also apply when multiple radiological diagnostic imaging procedures are performed on contiguous parts of the body, listed as family-group procedures. When multiple procedures are performed within these groups or families of procedures, the 25% multiple payment reduction shall apply to the technical component only. The agency shall publish in a manual separate from these rules a table listing groups of related codes (families). When more than 1 procedure from each group (family of contiguous codes) is performed on the same date of service, the technical component for the first procedure within each group is paid at 100% of the maximum
allowable payment. Each additional procedure within the group shall have modifier –51 appended and the technical component shall be reduced to 75% of the maximum allowable payment, or the provider’s charge, whichever is less.
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-04 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 administration of therapeutic injections when billing an evaluation and management procedure code. If an evaluation and management procedure code is not listed, then the appropriate medication administration procedure code may be billed.
(2) The medication being administered shall be billed with either 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 of the CMS 1500.
(4) The carrier shall reimburse the medication in accordance with R 418.101003a.
(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 418.10909 Billing for home health services.
Rule 909. (1) Services provided by a home health agency are considered ancillary services requiring a physician’s prescription certifying medical necessity. A copy of the prescription shall be attached to the bill.
(2) A home health agency shall submit charges to the workers’ compensation carrier using the UB-04 claim form.
(3) A home health agency shall use procedure codes from “HCPCS, Medicare’s National Level II Codes” adopted by reference in R 418.10107 to identify services provided.
(4) A home health agency may not bill for the services of a social worker unless the certified social worker is providing medically necessary therapeutic counseling.
(5) A home health agency may bill supplies with 99070, the unlisted CPT® code for miscellaneous supplies, or the appropriate supply code from “Medicare’s National Level II Codes HCPCS” as adopted by reference in R 418.10107.
(6) When a procedure code is described by “HCPCS, Medicare’s Level II” as per diem, the “by report” service is reimbursed per visit. When “HCPCS, Medicare’s Level II” describes a service as time-based the service is “by report,” and the procedure is reimbursed according to the time provided.
R 418.10912 Billing for prescription medications.
Rule 912. (1) Prescription drugs may be dispensed to an injured worker by either an outpatient pharmacy or a health care organization as defined in these rules. These rules shall apply to the pharmacy dispensing the prescription drugs to an injured worker only after the pharmacy has either written or oral confirmation from the carrier that the prescriptions or supplies are covered by workers’ compensation insurance.
(2) 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-G to describe the dispense fee for each generic prescription drug and WC700-B to describe the dispense fee for each brand name 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 418.10913 Billing for durable medical equipment and supplies.
Rule 913. (1) Durable medical equipment (DME) and supplies shall be billed using the appropriate descriptor from HCPCS, Medicare’s National Level II codes, as referenced in R 418.10107, for the service. If the equipment or supply is billed using an unlisted or not otherwise specified code and the charge exceeds $35.00, then an invoice shall be included with the bill.
(2) Initial claims for rental or purchased DME shall be filed with a prescription for medical necessity, including the expected time span the equipment will be required.
(3) Durable medical equipment may be billed as a rental or a purchase. If possible, the provider and carrier shall agree before dispensing the item as to whether it should be a rental or a purchased item. With the exception of oxygen equipment, rented DME is considered purchased equipment once the monthly rental allowance exceeds the purchase price or payment of 12 months rental, whichever comes first.
(a) If the worker’s medical condition changes or does not improve as expected, then the rental may be discontinued in favor of purchase.
(b) If death occurs, rental fees for equipment will terminate at the end of the month and additional rental payment shall not be made.
(c) The return of rented equipment is the dual responsibility of the worker and the DME supplier. The carrier is not responsible and shall not be required to reimburse for additional rental periods solely because of a delay in equipment returns.
(d) Oxygen equipment shall be considered a rental as long as the equipment is medically necessary. The equipment rental allowance includes reimbursement for the oxygen contents.
(4) A bill for an expendable medical supply shall include the brand name and the quantity dispensed.
(5) A bill for a miscellaneous supply, for example; a wig, shoes, or shoe modification, shall be submitted on an invoice if the supplier is not listed as a health care professional.
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-04 claim form to the carrier. A copy of the UB-04 form shall be published separate from these rules in a manual distributed by the health care services division of the agency. The Official UB-04 Data Specifications 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 418.10922 Hospital billing instructions.
Rule 922. (1) A hospital shall bill facility charges on the UB-04 national uniform billing claim form and shall include revenue codes, ICD.9.CM coding, HCPCS codes, and CPT® codes to identify the surgical, radiological, laboratory, medicine, and evaluation and management services. This rule only requires that the following medical records be attached when appropriate:
Emergency room report.
The initial evaluation and progress reports every 30 days whenever physical medicine, speech, and hearing services are billed.
The anesthesia record when billing for a CRNA or anesthesiologist.
(2) A properly completed UB-04 shall not require attachment of medical records except for those in sub rule (1) of this rule to be considered for payment. Information required for reimbursement is included on the claim form. A carrier may request any additional records under R 418.10118.
(3) 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.”
(4) A hospital system-owned office practice shall bill services on the CMS 1500 claim form using the office site of service and shall not bill facility fees.
(5) A hospital or hospital system-owned industrial or occupational clinic providing occupational health services shall bill services on the CMS 1500 claim form using the office site of service and 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 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-04.
(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.
(b) 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 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 post-operative 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-04 national uniform billing claim form and shall include the revenue codes contained in the Official UB-04 Data Specifications 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-04 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.
R 418.101002a Conversion factor for practitioner services.
Rule 1002a. (1) The workers' compensation agency shall determine the conversion factor for medical, surgical, and radiology procedures. The conversion factor shall be used by the workers' compensation agency for determining the maximum allowable payment for medical, surgical, and radiology procedures. The maximum allowable payment shall be determined by multiplying the appropriate conversion factor times the relative value unit assigned to a procedure. The relative value units are listed for the medicine, surgical, and radiology procedure codes in a manual separate from these rules. The manual shall be published annually by the workers' compensation agency using codes adopted from “Physicians’ Current Procedural Terminology (CPT®)” as referenced in R 418.10107 (a). The workers' compensation agency shall determine the relative values by using information found in the “Medicare RBRVS: The Physicians’ Guide” as adopted by reference in R 418.10107 (c).
(2) The conversion factor for medicine, radiology, and surgical procedures shall be $50.20 for the year 2008and shall be effective for dates of service on 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.
(e) Home health services.
(3) Orthotic and prosthetic procedures, L0100-L8499, that have assigned maximum allowable payments shall be listed in R 418.101504. Orthotic and prosthetic procedures not listed in R 418.101504 shall be by report
R 418.101003a Reimbursement for dispensed medications
Rule 101003a. (1) Prescription medication shall be reimbursed at the average wholesale price (AWP) minus 10%, as determined by the Red Book, referenced in R 418.10107, plus a dispense fee.
(a) The dispense fee for a brand name drug shall be $3.50 and shall be billed with WC700-B.
(b) The dispense fee for a generic drug shall be $5.50 and shall be billed with WC700-G.
(2) Over-the-counter drugs (OTC’s), dispensed by a provider other than a pharmacy, shall be dispensed in 10-day quantities and shall be reimbursed at the average wholesale price, as determined by the Red Book, or $2.50, whichever is greater.
R 418.101005 Reimbursement for home health services.
Rule 1005. (1) Home health services are reimbursed “by report,” requiring submission of a report with the charges on the UB-04 claim form. The carrier shall reimburse the home health agency according to each “by report” procedure listed on the UB-04, billed with the appropriate HCPCS code in accord with R 418.10909.
(2) Home health services shall be reimbursed by the carrier at either the provider’s usual and customary charge as defined by these rules or reasonable amount, whichever is less.
(3) Services listed in “HCPCS, Medicare Level II Codes” as adopted by reference in R 418.10107 as per diem shall be reimbursed per diem or per visit in accord with the description of the code. The per diem visit shall be either at the provider’s usual and customary charge or reasonable amount, whichever is less.
(4) Supplies and durable medical equipment (DME) shall be reimbursed pursuant to these rules.
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-04 national uniform billing claim form 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-04 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 418.101023 Reimbursement for 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. 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 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).
(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 shall 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) If an item is implanted during the surgical procedure and the freestanding surgical outpatient facility bills the implant and includes the copy of the invoice, then the implant shall be reimbursed at the cost of the implant plus a percent markup as follows:
(a) Cost of implant: $1.00 to $500.00 shall receive cost plus 50%.
(b) Cost of implant: $500.01 to $1000.00 shall receive cost plus 30%.
(c) Cost of implant: $1000.01 and higher shall receive cost plus 25%.
(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 post-operative 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 418.101003b.
