Section 418.10106. Procedure codes; relative value units; other billing information.

Rule 106. (1) Upon annual promulgation of R 418.10107, the health care services

division of the workers' compensation agency shall provide separate from these rules a manual, tables, and charts containing all of the following information on the agency’s website, www.michigan.gov/wca:

(a)   All Current Procedural Terminology (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 and coding instructions for medicine, surgery, and radiology services shall be adopted from the most recent publication entitled

"Current Procedural Terminology (CPT®)" as adopted by reference in R

418.10107. However, billing and coding guidelines published in the CPT codebook do not guarantee reimbursement. A carrier shall only reimburse medical procedures for a work-related injury or illness that are reasonable and necessary and are consistent with accepted medical standards.

(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 the state of Michigan. The geographical information, (GPCI), for these rules is a melded average using 60% of the figures published for the city of Detroit added to 40% of the figures published for the rest of this 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 "HCPCS 2014 Level II Professional Edition" as adopted by reference in R 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)     Medical services shall be considered “By Report” (BR) if a procedure code listed in “HCPCS 2014 Level II Professional Edition” or “Current Procedural Terminology (CPT®) 2014 Professional Edition” as adopted by reference in R 418.10107 does not have an assigned value.

History: 1998-2000 AACS; 2003 AACS; 2004 AACS; 2014 AACS.