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DEPARTMENT OF LABOR & ECONOMIC GROWTH WORKERS’ COMPENSATION AGENCY
WORKERS’ COMPENSATION HEALTH CARE SERVICES
Filed with the Secretary of State on March 2, 2006
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 418.10107, R 418.10212, R 418.10913, R 418.10922, R 418.101001, R 418.101002, R 418.101003,
R 418.101023, and R 418.101504, are amended, R 418.10916 is rescinded, and R 418.101003b is added to the Michigan Administrative Code.
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:0876, order # EP054106CKF, 1-800-621-8335. The publication may be purchased at a cost of $91.95, plus $11.95 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, 2006," copyright December 2005, published by the American Medical Association, P.O. Box 930876 Atlanta GA 31193-0876, order # OP095106CKF, customer service 1-800-621-8335. The publication may be purchased at a cost of $89.95, plus $11.95 for shipping and handling as of the time of adoption of these rules.
(c) “Medicare RBRVS 2005: The Physicians’ Guide,” published by the American Medical Association, 515 North State Street, Chicago IL, 60610, order #OPO59605CFJ, 1-800-621-8335. The publication may be purchased at a cost of $84.95, plus $11.95 shipping and handling as of the time of adoption of these rules.
(d) “Medicare RBRVS 2006: 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.
(e) "International Classification of Diseases, ICD-9-CM 2006 Volumes 1 & 2", copyright September 2005, American Medical Association, P.O. Box 930876, Atlanta GA 31193-0876,
order #OP065306CKF, 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) "2005 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
$76.95, plus $9.95 for shipping and handling as of the time of adoption of these rules.
(g) "Michigan Uniform Billing Manual," developed in cooperation with the American Hospital Association's National Uniform Billing Committee, published by Michigan Health and Hospital Association, Attn: UB-92 Subscriptions, 110 W. Michigan, Ste 1200, Lansing, MI 48933, 517-703- 8622. As of the time of adoption of these rules, the cost of the publication is $160.00, plus 6% sales tax.
R 418.10212 Physical and occupational therapy; physical medicine services.
Rule 212. (1) For the purposes of workers’ compensation, physical medicine services, procedure codes 97010-97799, shall be referred to as “physical treatment”when the services are provided by a practitioner other than a physical therapist or an occupational therapist. Physical therapy means physical treatment provided by a licensed physical therapist. Occupational therapy means physical treatment provided by an occupational therapist.
(2) Physical medicine services shall be restorative. If documentation does not support the restorative nature of the treatment, then the service shall not be reimbursed.
(3) Any of the following may provide physical treatment, to the extent that licensure, registration, or certification law allows:
A doctor of medicine.
A doctor of osteopathic medicine and surgery.
(c) A doctor of dental surgery.
(d) A doctor of chiropractic.
(e) A doctor of podiatric medicine and surgery.
(f) A physical therapist.
(g) An occupational therapist.
(4) Only a licensed physical therapist, certified occupational therapist, or licensed practitioner may use procedure codes 97001-97004 to describe the physical medicine and rehabilitation evaluation services. Job-site evaluations may be paid to a certified occupational therapist, a licensed physical therapist, or a physician. Job-site evaluations for workers’ compensation are by report and are described on the bill using codes WC500-WC600.
(5) If a practitioner performs and bills for physical treatment, then the practitioner shall do all of the following:
(a) Perform an initial evaluation.
(b) Develop a treatment plan.
(c) Modify the treatment as necessary.
(d) Perform a discharge evaluation.
The practitioner shall provide the carrier with an initial evaluation and a progress report every 30 calendar days and at discharge. Documentation requirements are the same as the requirements in R 418.10204(2).
(6) A provider shall report procedure code 97750 to describe a functional capacity evaluation. The carrier shall reimburse a maximum of 24 units or 6 hours for the initial evaluation. Not more than 4 additional units shall be billed for a re-evaluation occurring within 2 months.
(7) Physical medicine modalities are those agents applied to produce therapeutic changes to tissue and include, but are not limited to, thermal, acoustic, light, mechanical or electric energy.
(a) Supervised modalities include procedure codes 97010-97028. These codes do not require direct 1-on-1 patient contact by the provider. These modalities shall be performed in conjunction with a therapeutic procedure including manipulative services or the modalities shall not be reimbursed.
(b) Constant attendance modalities are those procedure codes 97032-97039 that require direct 1-on-1 patient contact by the provider.
(8) Therapeutic procedure codes 97110-97546 are procedures that effect change through the application of clinical skills and services that attempt to improve function. The physician or therapist shall have direct 1-on-1 patient contact.
(9) The following provisions apply to the listed modality services:
(a) Whirlpool shall only be reimbursed when done for debridement or as part of a restorative physical treatment program.
(b) Procedure 97010 shall not be reimbursed if the practitioner bills an evaluation and management service on the same date. Procedure code 97010 shall be used to bill hot or cold agents for any of the following reasons:
(i) Hot packs.
(ii) Hydrocollator packs.
(iii) Heat lamps.
(iv) Medconsonolator.
(v) Cryotherapy agents.
(vi) Ice melts and ice massage.
(vii) Vaporizing liquids.
(viii) Refrigerated units.
(ix) Chemical packs.
(x) Cold packs.
(c) Not more than 1 deep heat procedure shall be billed on the same date of service for the same diagnosis. Deep heat procedures include diathermy, microwave, ultrasound, and phonophoresis.
(d) Phonophoresis shall be billed using procedure code 97035 with modifier code -22 and shall be reimbursed at the same rate as procedure code 97035, plus $2.00 for the active ingredient used in the process. Phonophoresis shall include the electrodes.
(e) Iontophoresis shall include the solution, medication, and the electrodes.
(f) Electrical stimulation shall include the electrodes.
(g) Procedure codes 97032, 97033, and 97035 shall not be reimbursed to a doctor of chiropractic.
(h) Fluidotherapy, a dry whirlpool treatment, shall be reported using code 97022.
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. Rented DME is considered purchased equipment once the monthly rental allowance exceeds the purchase price or payment of 12 months rental, whichever comes first.
If the worker’s medical condition changes or does not improve as expected, then the rental may be discontinued in favor of purchase.
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.
(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 418.10916 Rescinded.
R 418.10922 Hospital billing instructions.
Rule 922. (1) A hospital 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 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-92 shall not require attachment of medical records except for those in subrule (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 418.101118.
(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 418.101001 General rules for practitioner reimbursement.
Rule 1001. (1) A provider that is authorized to practice in the state of Michigan shall receive the maximum allowable payment in accordance with these rules. A provider shall follow the process specified in these rules for resolving differences with a carrier regarding payment for appropriate health care services rendered to an injured worker. Reimbursement shall be based upon the site of service. The agency shall publish the maximum allowable payment for a procedure performed in the non-facility setting and the maximum allowable payment for a procedure performed in the facility setting.
(2) A carrier shall not make a payment for a service unless all required review activities pertaining to that service are completed.
(3) A carrier’s payment shall reflect any adjustments in the bill made through the carrier’s utilization review program.
(4) A carrier shall pay, adjust, or reject a properly submitted bill within 30 days of receipt. The carrier shall notify the provider on a form entitled “Carrier’s Explanation of Benefits” in a format specified by the agency. A copy shall be sent to the injured worker.
(5) A carrier shall not make a payment for any service that is determined inappropriate by the carrier’s professional health care review program.
(6) The carrier shall reimburse the provider a 3% late fee if more than 30 calendar days elapse between a carrier’s receipt of a properly submitted bill and a carrier’s mailing of the payment.
(7) If a procedure code has a maximum fee of “by report,” the provider shall be paid its usual and customary charge or the reasonable amount, whichever is less. The carrier shall provide an explanation of its determination that the fee is unreasonable or excessive in accordance with these rules.
R 418.101002 Conversion factors for medical, surgical, and radiology procedure codes; wage index factors for freestanding surgical outpatient facility.
Rule 1002. (1) The workers' compensation agency shall determine the conversion factors for medical, surgical, and radiology procedures. The conversion factor shall be used by the workers' compensation agency for determining the maximum allowable payment for medical, surgical, and radiology procedures. The maximum allowable payment shall be determined by multiplying the appropriate conversion factor times the relative value unit assigned to a procedure. The relative value units are listed for the medicine, surgical, and radiology procedure codes in a manual separate from these rules. The manual shall be published annually by the workers' compensation agency using codes adopted from “Physicians’ Current Procedural Terminology (CPT®)” as referenced in R 418.10107(a). The workers' compensation agency shall determine the relative values by using information found in the “Medicare RBRVS: The Physicians’Guide” as adopted by reference in R 418.10107(c).
(2) The conversion factor for medicine, radiology, and surgical procedures shall be $49.22 for the year 2006 and shall be effective for dates of service on the effective date of these rules.
(3) The wage index used to determine the maximum allowable payment for a surgery performed in a freestanding surgical outpatient facility for 2006 shall be 1.0678 and 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.
Vision and prosthetic optical services. Hearing aid services.
Home health services.
(3) Prescription medication shall be reimbursed at the average wholesale price (AWP) plus a $4.00 dispense fee for each drug, as determined by the Red Book, referenced in R 418.10107.
(4) Over-the-counter drugs (OTC’s), dispensed by a provider other than a pharmacy, shall be dispensed in 10-day quantities and shall be reimbursed at the average wholesale price, as determined by the Red Book, or $2.50, whichever is greater.
(5) 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.
R418.101003b Reimbursement for durable medical equipment and supplies.
Rule 1003b. (1) The carrier shall reimburse durable medical equipment (DME) and supplies at Medicare plus 5%. The health care services division shall publish the maximum allowable payments for DME and supplies in the manual separate from these rules.
(2) Rented DME shall be identified on the provider’s bill by RR. Modifier NU will identify the item as purchased, new.
(3) If a DME or supply exceeding $35.00 is not listed in the fee schedule, or if the service is billed with a not otherwise specified code, then reimbursement shall be invoice cost plus a percent mark-up as follows:
Invoice cost of $35.01 to $100 shall receive cost plus 50%. Invoice cost of $100.01 to $250.00 shall receive cost plus 30%. Invoice cost of $250.01 to $700.00 shall receive cost plus 25%. Invoice cost of $700.01 or higher shall receive cost plus 20%.
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. The surgical procedures shall be classified into 1 of 9 groupers, numbered 1-9. An allowable rate is assigned to each grouper and the payment is determined by multiplying the grouper rate times a wage index. The rates for the groupers shall be published by the agency in the Health Care Services Manual. The wage index shall be determined by the workers’ compensation agency and shall be published in the Health Care Services Manual.
(2) The state of Michigan workers’ compensation health care services rules shall adopt the payment system described in subrule (1) of this rule adding 80% to the rate reflecting a payment that is 80% higher than Medicare. The geographical wage-index used to calculate the facility payment for the surgical procedures shall represent urban Michigan and shall be listed in R 418.101002. 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 mark-up 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. Preoperative 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.
R 418.101504 Orthotic and prosthetic procedures and maximum allowable payments.
Rule 1504. The orthotic and prosthetic procedures that have set fees are listed in this rule. The maximum allowable fees for the selected orthotic and prosthetic procedures are listed in the table in this rule. All other orthotic and prosthetic procedures not included in this rule shall be considered by report procedures.
Code
L0120
MAP
$17.29
Code
L1090
MAP
$79.64
Code
L1880
MAP
$550.82
L0130
$117.02
L1100
$138.17
L1900
$234.40
L0140
$42.00
L1110
$221.90
L1902
$52.02
L0150
$74.60
L1120
$34.51
L1904
$333.00
L0160
$119.82
L1200
$1,424.25
L1906
$86.17
L0170
$796.31
L1210
$227.34
L1910
$174.27
L0172
$110.00
L1220
$192.48
L1920
$286.29
L0174
$194.07
L1230
$493.91
L1930
$175.57
L0180
$314.44
L1240
$67.46
L1940
$429.68
L0190
$407.89
L1250
$62.77
L1945
$1,145.70
L0200
$430.12
L1260
$65.74
L1950
$647.18
L0210
$28.85
L1270
$67.32
L1960
$530.36
L0220
$90.00
L1280
$74.95
L1970
$618.24
L0700
$1,779.93
L1290
$68.29
L1980
$318.88
L0710
$1,882.90
L1300
$1,451.36
L1990
$459.09
L0810
$2,371.87
L1310
$1,493.46
L2000
$881.27
L0820
$1,876.79
L1499
BR
L2010
$803.35
L0830
$2,829.65
L1500
$1,650.36
L2020
$1,132.33
L0860
$960.00
L1510
$828.93
L2030
$880.19
L0960
$60.01
L1520
$1,486.64
L2036
$2,022.35
L0970
$99.30
L1685
$1,033.49
L2037
$1,447.16
L0972
$89.42
L1686
$653.04
L2038
$1,024.83
L0974
$155.56
L1800
$43.34
L2040
$154.26
L0976
$138.95
L1810
$81.00
L2050
$413.88
L0978
$167.24
L1815
$63.13
L2060
$504.44
L0980
$15.17
L1820
$103.00
L2070
$116.84
L0982
$14.15
L1825
$35.83
L2080
$312.50
L0984
$47.18
L1830
$57.01
L2090
$380.99
L1000
$1,763.98
L1832
$480.05
L2106
$747.33
L1010
$58.31
L1834
$674.46
L2108
$1,170.03
L1020
$75.11
L1840
$798.89
L2112
$304.03
L1025
$108.35
L1844
$734.88
L2114
$440.38
L1030
$55.27
L1845
$583.78
L2116
$537.16
L1040
$67.79
L1846
$985.10
L2126
$1,356.79
L1050
$72.34
L1850
$187.57
L2128
$1,498.50
Code
L1060
MAP
$83.09
Code
L1855
MAP
$954.77
Code
L2132
MAP
$525.66
L1070
$78.18
L1858
$1,221.93
L2134
$803.12
L1080
$48.08
L1860
$1,383.48
L2136
$878.87
L1085
$133.74
L1870
$909.28
L2180
$101.75
L2182
$79.63
L2525
$873.78
L3030
BR
L2184
$107.63
L2526
$595.12
L3040
BR
L2186
$130.80
L2530
$204.14
L3050
BR
L2188
$260.22
L2540
$367.33
L3060
BR
L2190
$59.45
L2550
$249.53
L3070
BR
L2192
$309.80
L2570
$413.84
L3080
BR
L2200
$41.30
L2580
$403.24
L3090
BR
L2210
$58.40
L2600
$178.44
L3100
BR
L2220
$71.16
L2610
$211.00
L3150
BR
L2230
$66.67
L2620
$232.31
L3215
$94.18
L2240
$72.66
L2622
$266.44
L3216
$108.00
L2250
$308.74
L2624
$287.71
L3217
$127.00
L2260
$174.17
L2627
$1,489.46
L3219
$102.87
L2265
$102.31
L2628
$1,455.67
L3221
$120.00
L2270
$46.67
L2630
$215.15
L3222
$150.00
L2275
$103.91
L2640
$291.98
L3230
$425.00
L2280
$393.43
L2650
$104.27
L3250
$381.00
L2300
$233.93
L2660
$161.94
L3251
$450.00
L2310
$106.88
L2670
$148.21
L3252
$300.00
L2320
$178.76
L2680
$135.96
L3253
$90.00
L2330
$341.16
L2750
$72.62
L3254
$38.00
L2335
$197.38
L2760
$52.79
L3257
$180.00
L2340
$388.32
L2770
$53.64
L3260
$60.00
L2350
$774.19
L2780
$58.80
L3265
$35.00
L2360
$44.96
L2785
$27.54
L3300
$42.00
L2370
$223.04
L2795
$57.13
L3310
$40.00
L2375
$99.17
L2800
$92.00
L3320
BR
L2380
$106.97
L2810
$67.86
L3330
$275.00
L2385
$116.38
L2820
$75.46
L3332
$18.00
L2390
$95.11
L2830
$81.62
L3334
$25.00
L2395
$101.95
L2840
$30.06
L3340
$70.00
L2397
$87.81
L2850
$42.15
L3350
$13.00
L2405
$44.22
L2999
BR
L3360
$15.00
Code MAP
L2415 $159.56
L2425 $158.17
L2492 $88.60
L2500 $274.10
L2510 $631.12
L2520 $374.57
L3000 $170.00
L3001 BR
L3002 $99.00
L3003 $99.00
L3010 $135.00
L3020 $99.00
L3370 $22.00
L3380 $32.00
L3390 $15.00
L3400 $56.00
L3410 $64.00
L3420 $32.00
L3430 $44.00
L3440 $35.00
L3500 BR
L3510 BR
L3520 BR
L3530 BR
L3540 BR
L3550 BR
L3560 BR
L3570 BR
L3580 BR
L3590 BR
L3595 BR
L3650 $37.82
L3660 $65.54
L3670 $72.11
L3700 $44.51
L3710 $78.83
L3720 $556.10
