Chapter 1
Overview and Guidelines
Introduction
The Health Care Services Policy Manual contains information regarding health services
provided to treat an injury or illness causally related to employment for Michigan
workers. The billing and payment information contained in this manual is based upon
information found in the Health Care Services Rules
The manual is organized as follows:
General Information (Chapters 1-5) outlines the general policies and
procedures applicable to all providers and payers.
Coding and Fee Information (Chapters 6-13) contains a chapter for each
category of medical service. The policies, procedures and the maximum
allowable payment (MAP) are listed in each category of service.
Ancillary Services (Chapter 14) contains coding and payment information for
services described with coding from Medicare’s National Level II Code book.
Hospital Services (Chapter 15) contains information regarding payment for
facility services and the hospital’s maximum payment ratios.
Bureau Information (Chapter 16) contains examples of forms and bureau
contact numbers.
The Health Care Services Manual was designed to be as user friendly as possible.
Suggestions for further improvements or to report any possible errors, please contact:
Bureau of Workers’ Disability Compensation
Health Care Services Division Administrator
PO Box 30016
Lansing MI 48909
Phone (517) 322-5433 Fax (517) 322-6689
Copyright Notice
Procedure codes and descriptors found in this manual are from the 2002 edition of
“Physicians’ Current Procedural Terminology (CPTTM)” published by the American
Medical Association (AMA). All rights reserved. Abbreviated descriptors are noted in
this manual. For a complete description of the procedure codes, refer to
“Physicians’ Current Procedural Terminology (CPTTM).”
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No fee schedules, relative value units (RVU’s) or conversion factors are included in the
CPTTM book. The AMA assumes no responsibility for the consequences attributed to or
related to any use or interpretation of any information contained or not contained in this
product.
The AMA does not directly or indirectly practice medicine nor dispense medical
services. The AMA assumes no liability for the data contained herein.
Providers Covered by the Rules
All providers of health care services must be licensed, registered or certified as defined
in the Michigan Public Health Code, Act 368 of 1978, (Articles 1,7,15,19, and Excerpts
from Article 5) as amended.
Evaluation and management services and minor surgical procedures performed by
nurse practitioners and physician assistants are billed with modifiers. Reimbursement is
adjusted to 85% of the MAP amount or the practitioner’s usual and customary charge,
whichever is less. Service level adjustment factors are as follows:
Nurse Practitioner
Physician’s Assistant
-AK
-AU
0.85
0.85
Mental health therapeutic services are reimbursed adjusted according to a service level
adjustment factor. Services billed by the following practitioners must be identified by the
listed modifiers and will be adjusted to 85% or 64%, depending on the service provider
noted by the modifier. No adjustment is necessary for diagnostic testing procedures
performed.
Certified Social Worker
Limited License Psychologist
Licensed Marriage & Family Therapist
Licensed Professional Counselor
Limited Licensed Counselor
Limited Licensed Marriage & Family Therapist
-AJ
-AL
-MF
-LC
-CS
-ML
0.85
0.85
0.85
0.85
0.64
0.64
Services Listed in the Manual
The state of Michigan workers’ compensation schedule of maximum allowable
payments is listed in this manual. Chapters 6-13 contain the policy and procedures
unique to that category and the services are listed in numeric order according to CPT TM
coding. The manual lists the CPTTM code, the RVU, the MAP and the follow-up days for
surgical procedures. Except where otherwise noted in this manual, billing
instructions listed in the “Physicians Current Procedural Terminology (CPTTM)”
shall apply.
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Chapter 1 Overview and Guidelines
Maximum Allowable Payment (MAP) Amounts
The maximum allowable payments in this manual are based upon the Health Care
Financing Administration’s (HCFA) resource-based relative value scale (RBRVS).
RBRVS attempts to ensure the fees are based on the resources used to provide each
service described by CPTTM procedural coding. Relative values are derived based on
the work involved in providing each service (practice expense involved including office
expenses and malpractice insurance expense), and applying specific geographical
indices, (GPCI), to determine the relative value unit (RVU). Michigan workers’
compensation is applying the following GPCI resulting from a meld using 60% of the
Detroit area GPCI and 40% of the rest of the state’s GPCI.
Work
Practice Expense
Malpractice
1.0236
.9888
2.5726
The following formula is applied to the information taken from HCFA to determine the
RVU for the state of Michigan workers’ compensation:
(Work RVU’s x 1.0236) + (Practice Expense RVU’s x .9888) + (Malpractice RVU’s x
2.5726) = RVU
Most MAP amounts in Chapters 6-13 (except for anesthesia services) are precalculated and listed as dollar amounts. The MAP amounts were determined by
multiplying the RVU times the conversion factor. The conversion factor for the CPTTM
procedure codes is found in R 418.101002 of the Health Care Services rules
Determining Payment
The MAP amounts listed in this manual represent the maximum allowable payments
that a provider can be paid for rendering services under the state of Michigan Workers’
Compensation Act. When a provider’s charge is lower than the MAP amount, or if a
provider has a contractual agreement with the carrier to accept discounts for lower fees,
payment is made at the lower amount.
Workers’ Compensation laws are state specific and these rules and fees apply to
providers licensed to practice in Michigan. A provider licensed by the state of Michigan
billing a carrier for a service must accept the maximum allowable payment and shall not
balance bill the worker (Refer to R 418.10105).
By Report” (BR) Services
When a CPTTM code does not have an assigned numeric RVU, the procedure will be
listed as BR (by report). A provider who submits a claim for a BR service(s) should
include all pertinent documentation, including an adequate definition or description of
the nature and extent of the service and the time, effort, and equipment necessary to
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Chapter 1 Overview and Guidelines
provide the service. A BR procedure is reimbursed at the provider’s usual and
customary charge or reasonable amount determined by the carrier, whichever is less.
Codes Not Listed in the Manual
Every effort has been made to include all of the CPT TM codes and the assigned relative
value units in this manual. Inclusion of the CPTTM code in the manual does not
guarantee compensability of the service. The carrier is responsible for reviewing the
service(s) to determine if the treatment is related to the work injury or illness.
When a procedure code is not listed in the manual but is listed in either the CPT TM book
or Medicare’s National Level II HCPCS for the date of service, the code shall be billed
and reimbursed at the provider’s usual and customary charge or reasonable amount,
whichever is less.
Independent Medical Evaluations (IME’s)
A carrier or employee may request an independent medical evaluation (IME). A
practitioner other than the treating practitioner must do an independent medical
examination. The IME is exempt from the Health Care Services Rules for cost
containment and payment is determined on a contractual basis. The carrier and
provider should address how diagnostic testing will be reimbursed in the contractual
agreement.
A carrier may request an examination to determine the medical aspects of the case.
This examination would be considered a confirmatory consult. The confirmatory consult
is billed with procedure codes 99271-99275 and paid in accord with the fees listed in the
Evaluation and Management Section of this manual.
Claim Filing Limitation
A provider should promptly submit their charges to the carrier to expedite claims
processing. The carrier is not required to reimburse claims submitted after one year
from the date of service except for:


Litigated cases
When subrogation has occurred
Do not submit claim forms or requests for reconsideration to the bureau, as the
bureau does not pay or review bills. The State of Michigan Workers’ Disability
Compensation Health Care Services Rules discusses this information in R 418.10113
and R 418.10901(3).
Rehabilitation Nurse or Nurse Case Managers
When a carrier assigns a nurse case-manager or a rehabilitation nurse to a worker’s
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Chapter 1 Overview and Guidelines
compensation case and the nurse accompanies the patient to physician-office visits, the
physician may bill RN001. The carrier will then reimburse the physician for RN001, a
work-comp code specific for Michigan, in addition to the office visit, and be paid for the
additional service. The fee for RN001 is listed in R 418.101501, Table 1501-A.
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Chapter 2
General Policy
This chapter contains the general information regarding medical services provided to
injured workers in the state of Michigan.
Employee Responsibilities
An employee receiving an injury or illness during the course of employment must report
the injury to his employer. The employer may direct care for the injured worker for the
first 10 days. Following the initial 10 days of care, the worker may treat with a
physician of his or her own choice as long as the worker notifies the carrier of
their choice. If an employee receives a bill from a health care provider for a covered
work injury, the employee should submit the bill to the employer or if known the worker’s
compensation carrier for payment.
Employer Responsibilities
The Workers’ Disability Compensation Act outlines in Section 315 that an employer
must furnish or cause to be furnished all necessary and reasonable medical, surgical,
and hospital services and medicines, other attendance or treatment recognized as legal,
for an employee receiving an injury or illness in the course of employment. The
employer has the right to direct the employee to a provider of the employer’s choice for
the first 10 days of care commencing for the injury or illness and should report the
injury to their workers’ compensation carrier.
The insured employer must promptly file with the bureau, the form 100, "Employer’s
Basic Report of Injury" reporting cases when the injury results in 7 or more days of
disability, specific loss or death. The insured employer must inform the provider of the
name and address of its insurer or the designated agent of the insurer to whom the
health care bills should be sent. If the insured employer receives a bill, the employer
shall promptly send the provider’s bill and documentation to the carrier.
Provider Responsibilities
A provider shall promptly bill the carrier on the proper claim form and attach any
documentation required by the Health Care Services Rules. When a provider bills the
carrier and receives no response in 30 days, the provider should send a second
copy of the bill to the carrier and add a 3% late fee.
The provider may file for an “Application for Mediation and Hearing,” (104B) for
unresolved claims (See Part 13 of the Rules and Chapter 4, pg. 4.5 of this manual)
when:
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
The provider has sent 2 bills to the carrier and waited a total of 60 days for
a case that has not been disputed.

Payment was not made in accord with the maximum payments
established by the Health Care Services Rules, or the carrier has disputed
utilization of the overall services. If the issue(s) are not resolved through
the reconsideration process, the provider may file a 104B.

When the worker has contested a carrier dispute and the case becomes
contested (worker files 104A for a Bureau hearing). Provider should file
a 104B to be added as an intervening party to the carrier/worker
dispute.
Note: If the worker has not contested the carrier’s denial, then the worker
or his health insurance is responsible for services disputed as not workrelated.
Carrier Responsibilities
When the carrier receives notice of an injury or illness, the carrier:
 Establishes a case record. When the carrier receives a bill from the provider and
does not have an injury report on file from the employer, the carrier should followup with the employer.
 Determines compensability.
 Reviews medical bills for payment. The carrier is required to pay the medical
services within 30 days of receipt of a provider’s properly submitted bill or
must pay the provider a self-assessed 3% late fee applied to the MAP.
 Notifies the provider of their decision to adjust or reject a medical provider’s bill
on a form entitled “The Carrier’s Explanation of Benefits.”
 The Health Care Services Division of the bureau determines the format for
this form.
 Changes to the format may not be made without bureau approval.
 A copy must be sent to the injured worker and the provider.
 A copy of the form, BWC-739 (Rev 02-01) is located in Chapter 16.
Certification of a Carrier’s Professional Review Program
The State of Michigan Workers’ Disability Compensation Act does not mandate
managed care or prior authorization for reimbursement of medical services. The carrier
is required to review the medical services provided to ensure that the services are
reasonable and related to the work injury or illness (refer to Part I,
R 418.10101, Scope of the Health Care Services Rules).
 Carrier will submit to the bureau form BWC-590 “Application for Certification
of Professional Review” attaching a current methodology detailing how their
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company performs review. A copy of the form is located in this manual in Chapter
16. The methodology is submitted every 3 years or whenever changes occur.
 If a current methodology is on file with the bureau for the carrier or the
reviewing entity, then only the application need be submitted. The carrier
should contact the bureau to see if the methodology on file with the bureau is
current.
 The carrier is required to re-submit an “Application for Certification of
Professional Review” 6 months prior to the expiration date of the certification.
 The carrier must re-submit when any of the following change:
1. Service Company
2. Review Company.
3. Substantial change in methodology (must also include the new
methodology).
 Certification of the carrier’s review program is generally granted for a period of 3
years.
 A copy of the certification is sent to the carrier, Service Company and Review
Company when appropriate.
Utilization Review
The carrier’s professional review program consists of both technical review and
professional review. Technical review is outlined in R 418.101203 and professional
review is discussed in R 418.101204.
1.
Technical Review
 Frequently done as a computer review designed to edit claims for workers’
compensation in Michigan.
 Carrier is responsible for determining accuracy of coding and edits performed by
the computer software. The Carrier’s Explanation of Benefits shall detail reasons
for recoding any procedure in accord with Part 13 of the rules.
 Determine that the amount billed for a procedure does not exceed the maximum
allowable payment established by the rules. The carrier is responsible for
determining accuracy of the technical computer review when performed. Include
the name of the software program used in the technical review process within the
methodology.
 Specifically identify what bills and case records the carrier refers for professional
health care review according to R 418.101205.
2.
Professional Review Program
 Must comply with R 418.101205, scope of professional health care review.
 Document the process ensuring confidentiality of worker-specific and providerspecific information.
 Utilization review will look at coding accuracy and compensability issues.
 Determines medical necessity and appropriateness of services.
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 Medical claims review is generally retrospective as Michigan law does not
mandate managed care, and is performed strictly for purposes of reimbursement.
 Most frequently performed by a registered nurse or other licensed health care
professional with suitable expertise in occupational injury or disease processes
and the billing process.
 Licensed health care professionals must develop criteria used in the carrier’s
review process.
 Submit license documentation for each professional, including full name,
professional license number, state of issue, date of expiration and any
restrictions on current licensure. Include the same documentation for the
medical/clinical director supporting reviewers.
Note: Trained non-clinical staff may be used in the application of these
criteria, when their duties have oversight by a licensed health professional.
3.
Peer Review
 May be performed when the claim is initially submitted or when any outstanding
issues cannot be mutually resolved through the written reconsideration process.
 The carrier may utilize peer review to support decisions made in the utilization
review process when the carrier and the provider cannot mutually resolve the
issues.
 Generally performed by a doctor of medicine, doctor of osteopathy, chiropractic
physician, or a physical therapist having the same clinical licensure as the
treating provider whose services are being reviewed.
 The methodology utilized by a carrier for professional review shall include a list of
all peer reviewers with their specialty and licensure information.
4.
Reconsiderations/Appeals (Outlined in Part 13 of the Rules)
 Carrier must pay a properly submitted bill in 30 days or pay the provider a 3%
late fee and the notice of payment is sent on the Carrier’s Explanation of
Benefits.
 If the provider disagrees with the utilization decision or the payment is not made
in accord with the rules, then the provider submits a written request for
reconsideration.
 If the carrier does not respond within 30 days to the provider’s request for
reconsideration or does not mutually resolve the outstanding issue, then the
provider should file an “Application for Mediation and Hearing” to the bureau on
the original orange form, sending a copy to the carrier.
Annual Medical Payment Report
A carrier is also required to submit an “Annual Medical Payment Report” to the
bureau documenting the number of medical only cases, the number of wage loss cases
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and the total dollars spent for health care for those cases. The reporting period will
begin each year on January 1 and end each year on December 31. A copy of the form
is located in Chapter 16. The Annual Medical Payment Report is due in the bureau by
February 28 for the preceding calendar year and should include:
 Carrier Information
 Signature, address and telephone number of person responsible for completion
of the form.
 The number of Medical-Only Cases and the total dollars spent for medical
services in that year. Medical-only is defined as those cases where no indemnity
was paid.
NOTE: Refer to the definition of a case in the Health Care Services Rules.
Each case will generally have multiple bills. Do not count each bill as a
case.
 The number of Wage-Loss/Indemnity Cases and the total dollars spent for
medical services in that year. Wage-loss is defined as those cases in which the
carrier paid wage-loss replacement. For the purposes of this Annual Medical
Payment Report, once wage-loss benefits are paid, the case will always be
reported as wage-loss.
 Report only medical expenses. Do not include payments for:
 Indemnity
 Mileage reimbursements
 Vocational rehabilitation
 Rehabilitation case management
 Independent medical evaluation(s)
Service Companies and Insurance Companies will report as follows:
 Service Companies
 Submit one consolidated report for all self-insured clients.
 Report any payments for “tail” claims and all current business.
 A separate list must be included listing all of the current self-insured
employers/group funds and “tail” claims represented in the report.
Note: When a service company administers claims for an insurance company,
the data must be forwarded to the insurance company and the insurance
company will submit the Annual Medical Payment Report. The insurance
company will be responsible for compiling the data and submitting one
consolidated report to the bureau.
 Self-Administered Employers or Self-Administered Group Funds
 Do not have a service company and are responsible for submitting their own
reports.
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 Insurance Companies
 May submit one consolidated report for all insurance companies within their
group. When more than one company is included in the report, a listing of
all the companies included must be attached.
Any service company business performed by an insurance company must be reported
on a separate consolidated report. The insurance company will report their “service
company business” in the same manner described above for service companies.
Required Documentation
Providers are required to submit documentation for the following: (See R 418.10901)












The initial visit
A progress report if still treating after 60 days
Evaluation for physical treatment (PT, OT, CMT, OMT)
A progress report every 30 days for physical treatment
An operative report or office note (if done in the office) for a surgical
procedure
A consultation
A written report is required whenever the professional component of an xray is billed
The anesthesia record for anesthesia services
A functional capacity or work evaluation
When billing a BR (By Report) service, a description of the service is
required
Whenever a modifier is used to describe unusual circumstances
Whenever the procedure code descriptors includes a written report
Medical Records. The provider’s medical record is the basis for determining
necessity and for substantiating the service(s) rendered; therefore, the carrier
may request the record. Medical records must be legible and include the
information pertaining to:
1. The patient’s history and physical examination appropriate to the level of
service indicated by the presenting injury or illness;
2. Operative reports, test results and consultation reports;
3. Progress, clinical or office notes that reflect subjective complaints of the
patient, objective findings of the practitioner, assessment of the problem(s),
and plan(s) or recommendation(s); and,
4. Disability, work restrictions, and length of time, if applicable.
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Chapter 2 General Policy
Copies of Records and Reports
A carrier or a carrier’s agent, a worker or a worker’s agent may request additional case
records other than those required by the Rules (See Rule 113 and Rule 114). Providers
are entitled to charge for the cost of copying the records. Only those records for a
specific date of injury are covered under the Health Care Services Rules. Those
records are reimbursed at 25 cents per page plus the actual cost of mailing. In addition,
an administration charge shall be paid for the staff’s time to retrieve and copy the record
and is paid as follows:
0-30 minutes
31-60 minutes
Each additional 30-minute increment
$3.50
$7.00
$3.50
The copying and handling charge applies to all reports and records except the original
copy required under the provision of Rule 113 and all other reports required by the
rules. The party requesting the records pays the copying charge.
For records other than those applying to the specific date of injury (case record) the
provider may bill their usual and customary charge.
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Chapter 3
Billing Policy
This chapter contains policies and procedures for providers submitting claims and for
payers reviewing and processing those claims. Specific instructions for completing
claim forms are found in Chapter 5. Additional billing information is contained in
Chapters 6-13 of this document. Each section contains billing information specific to the
category of services listed in that section.
Billing Information
Providers must submit charges to the carriers on the appropriate health insurance claim
form. Documentation required by the rules must be legible. A carrier must pay only
licensed providers. When a provider treats an injured worker, the claim is sent to the
workers’ compensation carrier. The provider shall be paid the maximum allowable
payment (MAP) allowed by the Health Care Services Rules for services to treat a
covered work injury or illness.
The following claim forms are adopted by the Health Care Services Rules for billing
medical services:




HCFA-1500 claim form for practitioner billing
UB-92 claim form to bill for facility services
Universal pharmacy claim form or an invoice for billing outpatient
pharmacy services
American Dental claim form for dental services
Note: A hospital owned occupational or industrial clinic is
considered a practitioner service.
If the carrier or employer makes the worker’s appointment and the employer or carrier
fails to cancel the appointment within 72 hours, the provider may bill for a missed
appointment (e.g., IME or confirmatory consult) using procedure code 99199.
Balance Billing
According to Michigan law, a provider may not bill the employee for any amount of the
charge for health care services provided for the treatment of a covered injury or illness.
A provider may not balance bill (refer to Rule 105):


The amount is disputed by utilization review
That amount exceeds the maximum allowable payment
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When there are balances due to the utilization review, the provider may send a request
for reconsideration to the carrier, and if unresolved, file a request for mediation
(unless the MAP was paid by the carrier).
Procedure Codes
Procedure codes from Physician’s Current Procedural Terminology (CPTTM) and
Medicare’s National Level Codes (HCPCS) as adopted by reference in the Health Care
Services Rules, 418.10107, are used to report medical services. CPT coding is used
primarily for services, and HCPCS codes are used to report supplies and durable
medical equipment as well as ancillary services such as dental services, hearing and
vision services. The CPTTM procedure codes and MAP amounts are listed in fee tables
contained in this manual. Services not listed in the schedule will be considered as “by
report” (BR).
Administered, Injectable Pharmaceuticals and Supplies Dispensed in the Practitioner’s
Office
When an injectable drug is administered along with an evaluation and management
service, the drug is billed and identified with CPT TM 99070 or the appropriate J Code
from HCPCS. The office notes must identify the drug administered. A therapeutic
injection administration fee is not paid in conjunction with an office visit. The drug is
reimbursed at average wholesale price (AWP).
When a physician dispenses a prescription drug from his office, the drug is reimbursed
at AWP plus a $4 dispense fee. The dispense fee cannot be paid more often than
every 10 days for each prescription drug. A dispense fee is not paid when over-thecounter (OTC) medications are dispensed.
Supplies dispensed from the practitioner’s office are billed with code 99070, or the
appropriate HCPCS code, and a report describing the service must be attached to the
bill. Supplies are reimbursed at AWP + not more than 50%.
Pharmacy Services
Outpatient pharmacies and providers dispensing prescription drugs or medical supplies
must have oral or written confirmation from the carrier that the services are for a
covered work injury along with instructions on where the bill is to be sent. Until the
carrier gives such direction, those providers are not bound by the Health Care Services
Rules.
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An outpatient or mail order pharmacy must submit charges for prescription
medications on either a universal pharmacy claim form or an invoice
statement.
Charges for prescription drugs dispensed from the doctor’s office or a
health care organization shall be submitted on a HCFA 1500.
The following apply to pharmacy services:

The generic drug must be dispensed unless the prescription is labeled
“Dispense as Written” (DAW).

The reimbursement for prescription drugs is the average wholesale price
(AWP) plus a $4 dispense fee for each prescription drug. Not more than
one dispense fee shall be paid for each drug every 10 days.

A bill for a prescription drug shall include:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Name of the drug and the manufacturer’s name
Strength of the drug
Quantity and the dosage of the drug
Name and address of the pharmacy or health care organization
Prescription number when dispensed by a pharmacy
Date dispensed
Who prescribed the medication
Patient name, address and social security number
National drug code as listed in Red Book
Supplies and durable medical equipment are reimbursed at AWP + not more than 50%.
The L-code procedures have fees established and are printed in the rules and
published in this manual.
Modifiers
A modifier is a two-digit number added to a CPTTM procedure code to explain a specific
set of circumstances. A two-alpha code may also be used to describe the practitioner
providing the service. For certain services and circumstances the use of a modifier is
required. The use of a modifier does not guarantee additional payment to the provider.
Submitting Claims for Payment
Providers are responsible for submitting claim forms to the carrier for payment. A
carrier is defined as an insurance company or a self-insured employer or self-insured
group fund or one of the funds specified in the Act. When a provider is unable to get
carrier information from the employer, contact the bureau at (517) 322-1885 with
the following information:
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

Employer name and address
Date of injury or date of first symptoms for reported illness
A provider can also obtain carrier information from the bureau website:
www.cis.state.mi.us/wkrcomp/ and clicking on the insurance coverage tab at the top of
the page and entering the employer information.
Collecting Medical Fees
The bureau does not review claims for payment or reimburse medical providers.
The carrier (insurance companies, self-insured employers or self-insured group funds,
or one of the funds specified in the Act) is responsible for claims management and
payment medical services as well as wage-loss benefits. Contact the carrier to
determine the status of the claim.
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Chapter 4
Payment Policy
This chapter contains policies and procedures governing the payment of workers’
compensation claims for medical services. The information herein will serve as a guide
to payers when determining appropriate payment for medical claims.
General Payment Policy
The carrier is required to reimburse for all medically necessary and reasonable health
services in accord with Section 315 of the Workers’ Disability Compensation Act. The
medical services must be performed by licensed, registered or certified health care
providers and services must be provided to the extent that licensure, registration or
certification law allows.
The amount paid will be the Maximum Allowable Payment (MAP), in accord with the
rules, or the provider’s usual and customary charge, whichever is less (this applies to
modified services as well). Payment will be made only for actual services rendered for
the covered work injury or illness.
Services Rendered by Providers Outside the State of Michigan.
When practitioners in states other than Michigan render services for Michigan workers,
the provider may or may not accept MAP made in accord with the Michigan fees. If an
out-of-state provider requests reconsideration of payment, the carrier may attempt to
negotiate the fee. However, if the provider refuses to negotiate fees, the carrier must
reimburse the provider’s charge. The worker is not responsible for any unpaid balances
of the provider’s charges and should be instructed to send any bills received to the
carrier for resolution.
Workers’ Compensation Laws are State-Specific
Workers’ compensation laws in Michigan apply only to Michigan workers. A
federal employee or an employee working for a company located outside of the state of
Michigan would not be covered under Michigan law. A Michigan provider may only
access the hearing system for workers’ compensation for medical services rendered to
Michigan workers.
When a provider treats a federal employee or a worker injured in another state’s
jurisdiction, the health services will be reimbursed in accord with either federal labor
laws or those of the specific state where the employee worked.
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Chapter 4 Payment Policy
Claims Review and Reduction
A carrier must ensure that their technical review programs (data software) result in
correct payments in accord with the maximum allowable payment (MAP) amounts
outlined in the rules.
A carrier shall perform utilization review for medical services to ensure that those
services are necessary, reasonable, and related to the work injury or illness. Licensed,
registered or certified health care professionals must perform utilization review, and
when necessary, peer review of medical services shall be completed by the carrier to
support their utilization decisions.
The carrier is responsible for reviewing medical claims for compensability and
determining the services are necessary and reasonable. The carrier is required to
perform professional review of the medical services whenever payments on a case
exceed $5,000.00, there is an inpatient admission, or on any case deemed appropriate
by the carrier.
Services Not Substantiated by Documentation
In a case where the reviewer cannot find evidence in the notes or operative
report that the service was performed, the charge for that service may be denied.
The EOB must indicate the reason for the denial.
Services Not Accurately Coded
When a service billed is supported by documentation, but the code selected by
the provider is not the most accurate code available to describe that service, the
disputed amount shall be limited to the amount of the difference between the
MAP of the code billed, and the MAP of the code recommended by the reviewer.
Therefore, the reviewer must not deny payment for the service, but recommend a
payment based on the more accurate code.
The carrier may not take the position that the provider’s acceptance of payment
constitutes agreement with the decision. The provider has the right to dispute
the decision requesting reconsideration and a hearing if not resolved through
reconsideration.
Examples of Common Coding Errors Include:

An office visit is coded at a higher level than substantiated by the medical
record

Two x-ray codes are billed when a single x-ray code describes the number
of views taken
4-2
Chapter 4 Payment Policy

A debridement code is billed with another code whose descriptor includes
the debridement
Providers can reduce the frequency of services being re-coded by
following guidelines within the CPTTM book for correct coding and
guidelines found in the Health Care Services Rules.
Determining Payment for “By Report” (BR) Services
Supplies and durable medical equipment are “by report” (BR) and require a description
of the service when billed. Reimbursement for the supplies and durable medical
equipment are AWP + not more than 50%.
Ancillary services (dental, hearing, vision, and home health services) and services
without an assigned RVU are reimbursed at a reasonable amount or the provider’s
usual and customary charge, whichever is less. “Reasonable” is defined for the
purposes of reimbursement as “a payment based upon the amount generally paid
in the state for a particular procedure code using data available from the provider,
the carrier, or the bureau.”
A provider may request reconsideration when the BR service is not reasonably
reimbursed.
Multiple Patient Visits
Unless substantiated by medical necessity, only one patient visit per day, per provider
may be paid. Generally when a provider sees a patient twice in one day for necessary
services, the values of the visits are added together and a higher level of service is
billed.
Separate Procedures
Certain services carry the designation “separate procedure” in their CPTTM descriptor.
These are services that are commonly performed as an integral part of a total service
and, as such, must not be paid as a separate procedure. When a “separate procedure”
is performed independently of, and not immediately related to other services, it may be
billed and paid.
Total Procedures Billed Separately
When two separate providers are submitting separate claims for certain diagnostic
procedures (neurological testing, radiology and pathology procedures, etc.) the services
are identified professional and technical portions of the service. When this occurs, the
carrier will pay according to the professional and technical components.
4-3
Chapter 4 Payment Policy
The billing procedures in Chapters 6-13 stipulate that providers must indicate on the
claim form that the technical and professional components were performed separately
by adding a modifier to the CPT code. Modifier -26 indicates that only the professional
component was performed; modifier -TC indicates that only the technical component
was performed.
Completion of the Explanation of Benefits (EOB) Form
The EOB form must be sent to the provider with a copy sent to the worker. The carrier
shall ensure that the following information is included on the EOB:

The provider charge, reimbursement allowed, and reason for the reduction. The
carrier may use a “reason-code” but must clearly provide a written explanation.

The EOB should tell the provider how to request reconsideration and what
information is needed.

If the check is not sent with the EOB there must be information included so that
the provider can relate specific payment to the applicable services (claimant,
procedure, and date of service).
Disputed Payments
When a provider is dissatisfied with a payer’s reduction or denial of a charge for a work
related medical service, the provider may submit to the carrier a written request for
reconsideration within 60 days of receipt of payment. The request must include a
detailed explanation for the disagreement, and documentation to substantiate the
charge/service in question. Providers may not dispute a payment because of
dissatisfaction with a MAP amount. Refer to Part 13 of the Rules for resolving
differences. When the provider is dissatisfied with payments resulting from contractual
agreements, the provider must refer to that agreement and not enter into the hearing
system for workers’ compensation.
Upon receipt of a request for reconsideration, the payer must review and re-evaluate
the original bill and accompanying documentation, using its own medical consultant or
peer review if necessary, and respond to the provider within 30 days of the date of
receipt. The payer’s response to the provider must explain the reason(s) behind the
decision and cite the specific policy or rule upon which the adjustment was made.
Mediation Applications (104B’s)
Medical providers, insurance companies, and self-insured employers may request a
mediation hearing through the bureau by submitting the “Application for Mediation and
Hearing” form (104B). A carrier may request a hearing to recover overpayments (refer
to Rule 119); however, providers of health care services most frequently request
hearings when those services have not been correctly paid. An injured worker may not
4-4
Chapter 4 Payment Policy
use the 104B to request a hearing or contest his case. The injured worker with
questions should be instructed to call the bureau at (517) 241-8999 or (888) 396-5041
when they have questions.
A Provider’s Reasons for Requesting Mediation Hearings:

No response to the provider’s bill.

Payment dispute unresolved though the reconsideration process.

A provider should file a 104B whenever he learns that the workers’ case
is contested (the carrier denied compensability and the worker filed a
104A form).
Note: When an injured worker does not dispute the carrier’s denial of a
case by submitting a 104A to the bureau, the worker or his health
insurance is responsible for the health services. A worker may not be
turned over to collections if there is a pending worker’s compensation
claim that has not been resolved by the magistrate.
The requesting party submits the original (orange) form to the bureau and sends a copy
to the carrier or provider as appropriate. The 104B form may be obtained from the
bureau. Documentation is not sent to the bureau with the application, but is taken to
the mediation site.
Ordering Forms
Bureau forms, including 104B forms, are obtained from the bureau. You may order
forms by one of the following methods:



Mail request to Claims Division, BWDC, PO Box 30016, Lansing MI 48909
Email to bwdcinfo@cis.state.mi.us
Fax (517) 322-1808.
All requests should include a contact name, phone number, company name, street
address, city, state, zip code, the name of the requested form, and quantity.
4-5
Chapter 5
Completing and Submitting Claims
This chapter contains specific instructions for completing medical claim forms. Failure
to provide the information in the manner requested herein may result in claims being
returned for correction, additional information, or denial.
Claims Prepared by a Billing Service
Claims prepared for a provider by a billing service must comply with all applicable
sections of this manual.
Completing the HCFA-1500 for Practitioner Billing
The HCFA-1500 is the standard claim form used for practitioner services. The
instructions listed below indicate the information required to process practitioner claims
for workers’ compensation cases. The HCFA 1500 (12-90) is the most recent format
and the preferred form.
Note: Radiologists, pathologists, ambulance services, and anesthesiologists are
not required to enter a diagnostic code.
HCFA-1500 (12-90) Claim Form Elements 1 through 33
1.
1a.
2.
3.
4.
5.
6.
7.
8.
9.
9a.
9b.
9c.
9d.
10.
11.
11a.
11b.
11c.
11d.
Mark other
Patient's social security number
Name of the patient
Patient's sex and date of birth
Name of the workers’ disability compensation carrier
Patient's complete address omitting the telephone number
Omit
Carrier address. Omit the telephone number
Omit
Enter the employer's name
Omit
Omit
Omit
Omit
Mark the appropriate boxes
Omit
Omit
Omit
Omit
Omit
5-1
Chapter 5 Completing and Submitting Claims
12.
13.
14.
15.
16.
17.
17a.
18.
19.
20.
21.
22.
23.
24a.
24b.
24c.
24d.
Omit
Omit
Date of the work-related accident or the first symptoms of work-related illness
Complete if appropriate and if known
Enter the month, day, and year if applicable
Name of the referring physician
Omit
Date if applicable
Omit
Mark appropriate box
Written diagnosis of the ICD-9-CM diagnostic code number
Omit
Omit
Date for each service, "from/to" dates may be utilized
Place of service code
Type of service code
Enter the procedure code and modifier if appropriate. Attach documentation to
explain unusual circumstances
24e. ICD-9-CM diagnostic code number
24f. Charge for each procedure billed
24g. Complete this column for multiple units or total minutes for anesthesia services
24h. Enter "DB" for duplicate bill with the date billed
24i. Omit
24j. Omit
24k. Omit
25.
Enter the provider’s FEIN
26.
Enter the patient's account or case number
27.
Omit
28.
Enter the total charges
29.
Omit
30.
Omit
31.
Enter the date of the bill
32.
Complete if applicable
33.
Practitioner’s name, license, registration or certification number, address, zip
code, and telephone number
Site of Service Codes Place in element 24b on the HCFA 1500 (12-90)
1 or 21 - Inpatient hospital.
2 or 22 - Outpatient hospital.
3 or 11 - Office or clinic.
4 or 12 - Patient home.
5 or 52 - Day care facility (psychiatric facility/part hospital).
7 or 32 - Nursing home/nursing facility.
8 or 31 - Skilled nursing facility.
9 or 41 - Ambulance (land).
0 or 99 - Other locations (other unlisted facility).
5-2
Chapter 5 Completing and Submitting Claims
A or 81 - Independent laboratory.
B or 24 - Other medical/surgical facility (free-standing outpatient surgical center).
C - Residential treatment center (adult foster care).
G or 23 - Emergency room - hospital.
J or 33 - Custodial care.
K or 34 - Hospice.
L or 42 - Ambulance (air or water).
M or 51 - Inpatient psychiatric facility.
N or 53 - Community mental health.
O or 56 - Psychiatric residential facility.
Type of service codes Place in element 24c on the HCFA 1500 (12-90)
1 - Medical care.
2 - Surgery.
3 - Consultation.
4 - Diagnostic x-ray.
5 - Diagnostic laboratory.
6 - Radiation therapy.
7 - Anesthesia.
8 - Assistance at surgery.
9 - Other medical service.
0 - Blood or packed red cells.
A - Used durable medical equipment.
F - Ambulatory surgical center.
H - Hospice.
L - Renal supplies in the home.
American Dental Association Claim Form
In the top two boxes:
Left. Mark appropriate box, pre-treatment estimate or statement of actual services.
Right. Enter the workers’ compensation carrier name and address.
Item 1. Patient Name, First, M.I., Last
Item 2. Mark "self."
Item 3. Enter the sex of the patient.
Item 4. Enter patient's birth date (MMDDYYYY).
Item 5. Omit.
Item 6. Enter the patient's complete mailing address.
Item 7. Enter the patient's social security number.
Item 8. Omit.
Item 9. Enter the employer's name.
Item 10. Enter the employer's complete mailing address.
Item 11. Omit.
Item 12-a. Omit.
Item 12-b. Omit.
5-3
Chapter 5 Completing and Submitting Claims
Item 13. Omit.
Item 14-a. Omit.
Item 14-b. Omit.
Item 14-c. Omit.
Item 15. Omit.
Item 16. Enter the name of the dentist or dental organization.
Item 17. Enter the dentist's or the dental- organization’s complete address.
Item 18. Enter the dentist's social security number or dental organization's FEIN.
Item 19. Enter the dentist's license number.
Item 20. Enter the dentist's telephone number.
Item 21. Enter the first visit for the current series of treatment.
Item 22. Mark appropriate box for place of treatment.
Item 23. Indicate if x-rays are enclosed and how many.
Item 24-30. Mark appropriate boxes. Enter the date of injury in Item 24.
Item 31. Enter the tooth number, a description of the service, and the date of service,
the procedure number, and the fee.
Item 32. Indicate with an "x" any missing teeth. Add remarks for unusual services.
Include any dental disorders that existed before the date of injury.
Facility Billing
Licensed facilities are to submit facility charges on the UB-92 claim form in accord with
the billing instructions provided in the UB-92 billing manual published by the Michigan
Health and Hospital Association. The workers’ compensation carrier is responsible for
ensuring that the form is properly completed prior to payment. A copy of the UB-92
billing manual can be obtained by contacting:
Michigan Health & Hospital Association
UB-92 Manual Subscription
6215 W. St. Joseph Hwy.
Lansing MI 48917
(517) 323-3443
Hospitals must submit charges for practitioner services on the HCFA 1500 claim form.
Examples of practitioner services billed by the hospital are:




Anesthesiologists or nurse practitioners
Radiologists
Hospital-owned physician practices
Hospital-owned occupational or industrial clinic
5-4
Chapter 6
Evaluation and Management
This section stipulates only those policies and procedures that are unique to Evaluation
and Management (E/M) Services. Additional policies and procedures that apply to all
providers are listed in Chapters 1-5 of this manual.
For the purposes of workers’ compensation, a provider may bill a new patient evaluation
and management service for each new date of injury. Additionally, a new patient visit
may also be billed every three years in accordance with Health Care Financing
Administration or HCFA regulations.
Levels of E/M Services
E/M codes are grouped into three categories: office visits, hospital visits, and
consultations. For complete instructions on identifying and billing E/M services, refer to
the Evaluation and Management Services Guidelines of the CPT TM Manual.
E/M service descriptors have 7 components. These components are: history,
examination, medical decision-making, counseling, coordination of care, nature of
presenting problem, and time.
An assessment of range of motion shall be included in the E/M service.
Range of motion shall not be paid as a separate procedure unless the procedure
is medically necessary and appropriate for the patient’s diagnosis and condition.
The level of an office visit (E/M) is not guaranteed and may change from
session to session. The level of service billed must be consistent with the type of
presenting complaint and supported by documentation in the record (example: a
minor contusion of a finger would not appropriately be billed with a complex level
of service, such as level 4 or 5).
An ice pack/hot pack is not payable as a separate service when performed with
an evaluation and management service.
Procedure codes 99450-99456 may not be used to describe an E/M service. The
practitioner should use codes 99201-99350 to describe services for an injured worker.
In addition, code 99499 may not be used to describe an office visit or hospital service
when documentation supports use of 99201-99350.
Office Visit With Ongoing Physical Treatment
An E/M service is only payable in conjunction with physical treatment when:
 Documentation supports a change in the signs and symptoms
 A separate identifiable service is performed (E/M billed with modifier -25)
Rev 2002
6-1
Chapter 6 Evaluation and Management
After-Hour Services
Add on procedure codes 99050-99054 are only payable for office services when the
practitioner is providing office services after normal office hours. These codes should
not be reimbursed when the services occur during the provider’s normal business hours
(example: hospital ER or a 24-hour clinic).
Office Visits and Administration of Injectable Medication
An injection administration code for the therapeutic Injectable medication is not payable
as a separate procedure when billed with an E/M service. The medication administered
in the therapeutic injection shall be billed with procedure code 99070; identified with the
NDC code, and be reimbursed at the average wholesale price of the drug (AWP). If an
E/M service is not billed, then the administration codes (90782-90799) may be billed in
addition to the drug.
Office Visits and Administration of Immunizations
An office visit may be billed and paid separately when an immunization procedure code
is billed. Immunizations are billed with procedure codes 90476-90748. An example of
an immunization is tetanus toxoid vaccine. The immunization vaccines are reimbursed
at the average wholesale price of the drug.
When procedure codes 90476-90748 are billed, the administration procedure is billed
with 90471 or 90472 in addition to the vaccine. Reimbursement for 90471 is $5.00 and
90472 is $7.50.
Supplies and Material (CPTTM 99070)
Supplies and materials provided by the physician or health care organization over and
above those usually included with the office visit are payable by the carrier. The
provider to describe the service uses procedure code 99070 or the appropriate HCPCS
code. Supplies are reimbursed at AWP + not more than 50%.
The following are examples of supplies usually included with the office visit:
Sterile or non-sterile
dressings, tape,
Antiseptic ointments &
solutions, Alcohol wipes
Gloves, Cotton-tipped
applicators
Butterfly dressings,
Cold or hot compress.
Minor educational
supplies
Syringes, Medicine
cups, Needles
Follow-up Days
When a service listed in the schedule is assigned a number of follow-up days, no
payment will be made for office visits or hospital visits for routine, normal follow-up care.
Rev 2002
6-2
Chapter 6 Evaluation and Management
Physicians may; however, charge for supplies furnished by the office. If the length of
follow-up care goes beyond the number of follow-up days indicated, the physician will
be allowed to charge for office/hospital visits.
Rev 2002
6-3
Chapter 7
Anesthesia
This section stipulates only those policies and procedures that are unique to anesthesia
services. Additional policies and procedures that apply to all providers are listed in
Chapters 1-5 of this manual.
General Information and Overview
Payment for an anesthesia service includes all usual pre-operative and post-operative
visits, the anesthesia care during the procedure, and the administration of fluids and/or
blood incidental to the anesthesia or surgery and usual monitoring procedures.
Specialized forms of monitoring (e.g., intra-arterial, central venous, and Swan-Ganz) are
not included in the anesthesia base. The anesthesia procedure code billed on the
HCFA 1500 reports the base units for the procedure. See the anesthesia table in
this chapter for a listing of the base units assigned to each anesthesia procedure.
To report regional or general anesthesia provided by the surgeon performing the
surgical procedure see modifier -47, Anesthesia by Surgeon, discussed in Chapter 7 of
this manual or in the CPTTM manual. When anesthesia is provided by the surgeon only
the base units shall be paid.
Time Reporting
Anesthesia time units are equivalent to 15-minute intervals for the actual administration
of the anesthesia and 30-minute intervals for supervision of a certified registered nurse
anesthetist (CRNA). Not less than the equivalent of one (15) minute unit for
administration or one (30) minute unit for supervision shall be paid.
Time is reported by placing the total number of minutes for the anesthesia
service in the days or units column on the HCFA 1500 claim form (element 24g on
the HCFA 1500 12-90).
Anesthesia time begins when the anesthesiologist (or CRNA) begins to prepare the
patient for the induction of anesthesia in the operating room or in an equivalent area
and ends when the anesthesiologist is no longer in personal attendance.
Determining Anesthesia Payment
Anesthesia services are reimbursed based upon total base units + total time units.
Anesthesia services may be performed and billed by an anesthesiologist, a certified
registered nurse anesthetist (CRNA), or both. The base units for a procedure are paid
only once for the anesthesia service. Whenever multiple surgical procedures are
performed, the anesthesia procedure with the greatest number of base units shall be
billed to describe the anesthesia base services.
7-1
Chapter 7 Anesthesia
Anesthesia services must be submitted on the HCFA 1500 using the anesthesia
procedure code and a modifier to identify the service provider. A copy of the
anesthesia record must be included. The carrier will reimburse as follows:
-AA is used when the anesthesiologist administers the anesthesia. The provider
is paid $42.00 for each base unit billed, plus $2.80 for each minute of anesthesia
administered and billed.
-SA is used when the anesthesiologist is supervising a CRNA. The provider is
paid $42.00 for each base unit billed, plus $1.40 for each minute of supervision.
-QX is used to describe CRNA services under the supervision of the
anesthesiologist. The CRNA is paid $2.80 for each minute of anesthesia
administered and billed.
-QZ is used to describe CRNA services performed without supervision of an
anesthesiologist. The CRNA in this instance would be paid the same as the
anesthesiologist billing with modifier -AA (base +$2.80 per minutes).
Note: The CRNA is generally supervised in most hospitals by an anesthesiologist.
Modifier -QZ cannot be billed on the same date as Modifier -AA or Modifier -SA for
an anesthesia service.
If the anesthesiologist employs the CRNA, the anesthesia service is billed on 2 lines of
the HCFA 1500. The anesthesia procedure code is billed with modifier SA designating
the anesthesiologist service and again on a second line with modifier QX to represent
the CRNA service.
Physical Risk Modifiers and Emergency Anesthesia
When a provider bills physical status modifiers, documentation shall be included with
the bill to support the additional risk factors. The physical status modifiers are assigned
unit values. When appropriate, the unit value would be added to the base units and be
paid at $42.00 per unit. The values assigned are:
P1
P2
P3
P4
P5
P6
A normal health patient
A patient with mild systemic disease
A patient with severe systemic disease
A patient with severe systemic disease that is a constant threat to life
A moribund patient who is expected not to survive without the operation
A declared brain-dead patient whose organs are being removed for donor
purposes
Procedure code 99140 would be billed as an add-on procedure when an emergency
condition complicates anesthesia. Documentation supporting the emergency must be
included with the bill.
7-2
0
0
1
2
3
0
Chapter 7 Anesthesia

Refer to the Health Care Services Rules, R 418.10108 (n) for a definition of
emergency condition.

On-call coverage does not meet criteria for billing 99140.
7-3
Anesthesia Fee Table
Each base Unit =$42.00
Code
Anesthesia Procedure Descriptions
00100
Anesthesia for procedures on Integumentary system of head and/or salivary
glands, including biopsy; not otherwise specified
5 $210.00
00103
00104
00120
Blepharoplasty
Anesthesia for electroconvulsive therapy
Anesthesia for procedures on external, middle, and inner ear, including biopsy;
not otherwise specified
5
4
5
$210.00
$168.00
$210.00
00124
00126
00140
00142
00144
00145
00148
00160
Otoscopy
Typmpanotomy
Anesthesia for procedures on eye, not otherwise specified
lens surgery
corneal transplant
Vitrectomy
Ophthalmoscopy
Anesthesia for procedures on nose and accessory sinuses; not otherwise
specified
radical surgery
biopsy, soft tissue
Anesthesia for intra-oral procedures, including biopsy; not otherwise specified
radical surgery
Anesthesia for procedures on facial bones; not otherwise specified
radical surgery (including prognathism)
Anesthesia for intracranial procedures; not otherwise specified
subdural taps
burr holes
elevation of depressed skull fracture, extradural (simple or compound)
vascular procedures
procedures in sitting position
spinal fluid shunting procedures
electrocoagulation of intracranial nerve
Anesthesia for all procedures on integumentary system of neck, including
subcutaneous and tissue
4
4
5
6
6
6
4
5
$168.00
$168.00
$210.00
$252.00
$252.00
$252.00
$168.00
$210.00
7
4
5
7
5
7
11
5
9
9
15
13
10
6
5
$294.00
$168.00
$210.00
$294.00
$210.00
$294.00
$462.00
$210.00
$378.00
$378.00
$630.00
$546.00
$420.00
$252.00
$210.00
6
$252.00
00162
00164
00170
00176
00190
00192
00210
00212
00214
00215
00216
00218
00220
00222
00300
Base
MAP
00320
Anesthesia for all procedures on esophagus, thyroid, larynx, trachea, and
lymphatic system of neck; not otherwise specified
00322
00350
00352
00400
needle biopsy of thyroid
Anesthesia for procedures on major vessels of neck; not otherwise specified
simple ligation
Anesthesia for procedures on anterior integumentary system of chest, including
subcutaneous tissue; not otherwise specified
3
10
5
3
$126.00
$420.00
$210.00
$126.00
00410
00450
00452
00454
00470
00472
00474
electrical conversion of arrhythmias
Anesthesia for procedures on clavicle and scapula; not otherwise specified
radical surgery
biopsy of clavicle
Anesthesia for partial rib resection; not otherwise specified
thoracoplasty (any type)
radical procedures (e.g., pectus excavatum)
4
6
6
3
6
10
13
$168.00
$252.00
$252.00
$126.00
$252.00
$420.00
$546.00
7-1
Anesthesia Fee Table
Each base Unit =$42.00
Code
Anesthesia Procedure Descriptions
00500
00520
Anesthesia for all procedures on esophagus
Anesthesia for closed chest procedures (including esophagoscopy,
bronchoscopy, diagnostic thoracoscopy); not otherwise specified
00522
00524
00528
00530
00532
00534
needle biopsy of pleura
pneumocentesis
mediastinoscopy
Anesthesia for transvenous pacemaker insertion
Anesthesia for access to central venous circulation
Anesthesia for transvenous insertion or replacement of cardioverter/defibrillator
Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and
mediastinum (including surgical thorascoscopy); not otherwise specified
00540
Base
MAP
15
6
$630.00
$252.00
4
4
8
4
4
7
$168.00
$168.00
$336.00
$168.00
$168.00
$294.00
13
$546.00
00542
00544
00546
00548
00560
decortication
pleurectomy
pulmonary resection with thoracoplasty
intrathoracic repair of trauma to trachea and bronchi
Anesthesia for procedures on heart, pericardium, and great vessels of chest;
without pump oxygenator
15
15
15
15
15
$630.00
$630.00
$630.00
$630.00
$630.00
00562
00580
00600
00604
00620
00622
00630
00632
00634
00670
with pump oxygenator
Anesthesia for heart transplant or heart/lung transplant
Anesthesia for procedures on cervical spine and cord; not otherwise specified
posterior cervical laminectomy in sitting position
Anesthesia for procedures on thoracic spine and cord; not otherwise specified
thoracolumbar sympathectomy
Anesthesia for procedures in lumbar region; not otherwise specified
lumbar sympathectomy
chemonucleoysis
Anesthesia for extensive spine and spinal cord procedures (e.g., Harrington rod
technique)
20
20
10
13
13
13
8
7
10
13
$840.00
$840.00
$420.00
$546.00
$546.00
$546.00
$336.00
$294.00
$420.00
$546.00
00700
Anesthesia for procedures on upper anterior abdominal wall; not otherwise
specified
3
$126.00
00702
00730
00740
00750
00752
00754
00756
00770
00790
percutaneous liver biopsy
Anesthesia for procedures on upper posterior abdominal wall
Anesthesia for upper gastrointestinal endoscopic procedures
Anesthesia for hernia repairs in upper abdomen; not otherwise specified
lumbar and ventral (incisional) hernias and/or wound dehiscence
omphalocele
transabdominal repair of diaphragmatic hernia
Anesthesia for all procedures on major abdominal blood vessels
Anesthesia for intraperitoneal procedures in upper abdomen, including
laparoscopy; not otherwise specified
4
5
5
4
6
7
7
15
7
$168.00
$210.00
$210.00
$168.00
$252.00
$294.00
$294.00
$630.00
$294.00
00792
00794
00800
partial hepatectomy (excluding liver biopsy)
pancreatectomy, partial or total (e.g., Whipple procedure)
Anesthesia for procedures on lower anterior abdominal wall; not otherwise
specified
panniculectomy
13
8
3
$546.00
$336.00
$126.00
5
$210.00
00802
Anesthesia -2
Anesthesia Fee Table
Each base Unit =$42.00
Code
Anesthesia Procedure Descriptions
00810
00820
00830
00832
00840
Anesthesia for intestinal endoscopic procedures
Anesthesia for procedures on lower posterior abdominal wall
Anesthesia for hernia repairs in lower abdomen; not otherwise specified
ventral and incisional hernias
Anesthesia for intraperitoneal procedures in lower abdomen including
laparoscopy;
abdominoperineal resection
cesarean section
Anesthesia for extraperitoneal procedures in lower abdomen; including urinary
tract; not otherwise specified
00844
00850
00860
Base
MAP
6
5
4
6
6
$252.00
$210.00
$168.00
$252.00
$252.00
7
7
6
$294.00
$294.00
$252.00
7
8
15
$294.00
$336.00
$630.00
00862
00864
00880
renal procedures, including upper 1/3 of ureter, or donor nephrectomy
total cystectomy
Anesthesia for procedures on major lower abdominal vessels; not otherwise
specified
00900
Anesthesia for procedures on perineal integumentary system (including biopsy
of male genital system); not otherwise specified
3
$126.00
00910
Anesthesia for transurethral procedures (including urethrocystoscopy); not
otherwise specified
3
$126.00
00920
00922
00926
00928
00930
00932
00934
00936
00938
00940
Anesthesia for procedures on male external genitalia; not otherwise specified
seminal vesicles
radical orchiectomy, inguinal
radical orchiectomy, abdominal
orchiopexy, unilateral or bilateral
complete amputation of penis
radical amputation of penis with bilateral inguinal lymphadenectomy
radical amputation of penis with bilateral inguinal and iliac lymphadenectomy
insertion of penile prosthesis (perineal approach)
Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or
endometrium); not otherwise specified
3
6
4
6
4
4
6
8
4
3
$126.00
$252.00
$168.00
$252.00
$168.00
$168.00
$252.00
$336.00
$168.00
$126.00
00944
00946
00948
00955
01120
01130
01140
01160
01170
01180
01190
01200
01202
01210
01212
01214
01220
vaginal hysterectomy
vaginal delivery
cervical cerclage
Continuous epidural analgesia, for labor and vaginal delivery
Anesthesia for procedures on bony pelvis
Anesthesia for body cast application or revision
Anesthesia for interpelviabdominal (hind quarter) amputation
Anesthesia for closed procedures involving symphysis pubis or sacroiliac joint
Anesthesia for open procedures involving symphysis pubis or sacroiliac joint
Anesthesia for obturator neurectomy; extrapelvic
intrapelvic
Anesthesia for all closed procedures involving hip joint
Anesthesia for arthroscopic procedures of hip joint
Anesthesia for open procedures involving hip joint; not otherwise specified
hip disarticulation
total hip replacement or revision
Anesthesia for all closed procedures involving upper 2/3 of femur
6
5
4
5
6
3
15
4
8
3
4
4
4
6
10
8
4
$252.00
$210.00
$168.00
$210.00
$252.00
$126.00
$630.00
$168.00
$336.00
$126.00
$168.00
$168.00
$168.00
$252.00
$420.00
$336.00
$168.00
Anesthesia -3
Anesthesia Fee Table
Each base Unit =$42.00
Code
Anesthesia Procedure Descriptions
01230
Anesthesia for open procedures involving upper 2/3 of femur; not otherwise
specified
6
$252.00
01232
01234
01250
amputation
radical resection
Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae
of upper leg
5
8
4
$210.00
$336.00
$168.00
01260
01270
Anesthesia for all procedures involving veins of upper leg, including exloration
Anesthesia for procedures involving arteries of upper leg, including bypass
graft; not otherwise specified
3
8
$126.00
$336.00
01272
01274
01320
femoral artery ligation
femoral artery embolectomy
Anesthesia for all procedures on nerves, muscles, tendons, fascia and bursae
of knee and/or popliteal area
4
6
4
$168.00
$252.00
$168.00
01340
01360
01380
01382
01390
Anesthesia for all closed procedures on lower 1/3 of femur
Anesthesia for all open procedures on lower 1/3 of femur
Anesthesia for all closed procedures on knee joint
Anesthesia for arthroscopic procedures of knee joint
Anesthesia for all closed procedures on upper ends of tibia, fibula, and or
patella
Anesthesia for all open procedures on upper ends of tibia, fibula and or patella
Anesthesia for open procedures on knee joint; not otherwise specified
total knee replacement
disarticulation at knee
Anesthesia for all cast applications, removal, or repair involving knee joint
Anesthesia for procedures on veins of knee and popliteal area; not otherwise
specified
4
5
3
3
3
$168.00
$210.00
$126.00
$126.00
$126.00
4
4
7
5
3
3
$168.00
$168.00
$294.00
$210.00
$126.00
$126.00
01432
01440
arteriovenous fistula
Anesthesia for procedures on arteries of knee and popliteal area; not otherwise
specified
5
6
$210.00
$252.00
01442
01444
01462
01464
01470
popliteal thromboendarterectomy, with or without patch graft
popliteal excision and graft or repair for occlusion or aneurysm
Anesthesia for all closed procedures on lower leg, ankle, and foot
Anesthesia for arthroscopic procedures of ankle joint
Anesthesia for procedures on nerves, muscles, tendons, and fascia of lower
leg, ankle, and foot; not otherwise specified
8
8
3
3
3
$336.00
$336.00
$126.00
$126.00
$126.00
01472
01474
01480
repair of ruptured Achilles tendon, with or without graft
gastrocnemius recession (e.g., Strayer procedure)
Anesthesia for open procedures on bones of lower leg, ankle, and foot; not
otherwise specified
5
5
3
$210.00
$210.00
$126.00
01482
01484
01486
01490
01500
radical resection
osteotomy or osteoplasty of tibia and/or fibula
total ankle replacement
Anesthesia for lower leg cast application, removal, or repair
Anesthesia for procedures on arteries of lower leg, including bypass graft; not
otherwise specified
4
4
7
3
8
$168.00
$168.00
$294.00
$126.00
$336.00
6
$252.00
01392
01400
01402
01404
01420
01430
01502
embolectomy, direct or with catheter
Anesthesia -4
Base
MAP
Anesthesia Fee Table
Each base Unit =$42.00
Code
Anesthesia Procedure Descriptions
01520
01522
01610
Anesthesia for procedures on veins of lower leg; not otherwise specified
venous thrombectomy, direct or with catheter
Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae
of upper leg
6
5
5
$252.00
$210.00
$210.00
01620
Anesthesia for all closed procedures on humeral head and neck,
sternoclavicular joint, acromioclavicular joint, and shoulder joint
4
$168.00
01622
01630
Anesthesia for arthroscopic procedures of shoulder joint
Anesthesia for open procedures on humeral head and neck, sternoclavicular
joint, acromioclavicular joint, and shoulder joint; not otherwise specified
4
5
$168.00
$210.00
01632
01634
01636
01638
01650
radical resection
shoulder disarticulation
interthoracoscapular (forequarter) amputation
total shoulder replacement
Anesthesia for procedures on arteries of shoulder and axilla; not otherwise
specified
6
9
15
10
6
$252.00
$378.00
$630.00
$420.00
$252.00
01652
01654
01656
01670
01680
axillary-brachial aneurysm
bypass graft
axillary-femoral bypass graft
Anesthesia for all procedures on veins of shoulder and axilla
Anesthesia for shoulder cast application, removal or repair; not otherwise
specified
shoulder spica
Anesthesia for procedures on nerves, muscles, tendons, fascia, and bursae of
upper arm and elbow; not otherwise specified
10
8
10
4
3
$420.00
$336.00
$420.00
$168.00
$126.00
4
3
$168.00
$126.00
tenotomy, elbow to shoulder, open
tenoplasty, elbow to shoulder
tenodesis, rupture of long tendon of biceps
Anesthesia for all closed procedures on humerus and elbow
Anesthesia for arthroscopic procedures of elbow joint
Anesthesia for open procedures on humerus and elbow; not otherwise
specified
osteotomy of humerus
repair of nonunion or malunion of humerus
radical procedures
excision of cyst or tumor of humerus
total elbow replacement
Anesthesia for procedures on arteries of upper arm and elbow; not otherwise
upper arm and elbow; not otherwise specified
5
5
5
3
3
5
$210.00
$210.00
$210.00
$126.00
$126.00
$210.00
5
5
6
5
7
6
$210.00
$210.00
$252.00
$210.00
$294.00
$252.00
01772
01780
embolectomy
Anesthesia for procedures on veins of upper arm and elbow; not otherwise
specified
6
3
$252.00
$126.00
01782
01784
01810
phleborrhaphy
Anesthesia for repair of arterio-venous (A-V) fistula, congenital or acquired
Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae
of forearm, wrist, and hand
4
6
3
$168.00
$252.00
$126.00
01820
Anesthesia for all closed procedures on radius, ulna, wrist, or hand bones
3
$126.00
01682
01710
01712
01714
01716
01730
01732
01740
01742
01744
01756
01758
01760
01770
Anesthesia -5
Base
MAP
Anesthesia Fee Table
Each base Unit =$42.00
Code
Anesthesia Procedure Descriptions
01830
Anesthesia for open procedures on radius, ulna, wrist, or hand bones; not
otherwise specified
3
$126.00
01832
01840
total wrist replacement
Anesthesia for procedures on arteries of forearm, wrist, and hand; not
otherwise specified
6
6
$252.00
$252.00
01842
01844
01850
embolectomy
Anesthesia for vascular shunt, or shunt revision, any type (eg, dialysis)
Anesthesia for procedures on veins of forearm, wrist, and hand; not otherwise
specified
6
6
3
$252.00
$252.00
$126.00
01852
01860
01904
01906
01908
01910
01912
01914
01916
01918
01920
phleborrhaphy
Anesthesia for forearm, wrist, or hand cast application, removal, or repair
Anesthesia for injection procedure for pneumoencephalography
Anesthesia for injection procedure for myelography; lumbar
cervical
posterior fossa
Anesthesia for injection procedure for diskography; lumbar
cervical
Anesthesia for arteriograms, needle; carotid, or vertebral
retrograde, brachial or femoral
Anesthesia for cardiac catheterization including coronary arteriography and
ventriculography (not to include Swan-Ganz catheter)
4
3
7
5
5
9
5
6
5
5
7
$168.00
$126.00
$294.00
$210.00
$210.00
$378.00
$210.00
$252.00
$210.00
$210.00
$294.00
01921
01922
01995
01996
01999
01999PA
99140
Anesthesia for angioplasty
Anesthesia for non-invasive imaging or radiation therapy
Regional IV administration of local anesthetic agent (upper or lower extremity)
Daily management of epidural or subarachnoid drug administration
Unlisted anesthesia procedure(s)
Patient Controlled Analgesia. Refer to R 418.10915 for payment conditions
Anesthesia performed as an emergency procedure
7
7
3
3
BR
$294.00
$294.00
$126.00
$126.00
BR
$137.00
$84.00
Anesthesia -6
Base
2
MAP
Chapter 8
Surgery
This section stipulates the policies and procedures that are unique to surgery.
Additional policies and procedures that apply to all providers are found in Chapters 1-5
of this manual.
General
The schedule of maximum allowable payment (MAP) amounts for surgery lists the
CPTTM code, a brief description of the procedure, the MAP amount and the follow-up
days (FUD). The starred (*) surgical procedures and those procedures allowing a
technical surgical assist (“T”) are also noted.
During the follow-up period no payment will be made for hospital or office visits for
routine normal, uncomplicated care, as those services are included in the global
package for the surgical procedure.
A claim for a surgical procedure (procedure codes 10040-69990) is considered
incomplete unless accompanied by an operative report. The office notes documenting
a surgical procedure performed are also considered the operative report for those
surgical procedures performed in the office setting.
Global Procedure (Package)
The payment for surgical procedures is based upon a global package concept. Global
payment requires that the service(s) performed be identified and billed using the fewest
possible CPTTM codes (“unbundling” is not allowed).
The global surgical procedure includes:

The immediate preoperative care (a consultation or an evaluation in an
emergency situation to evaluate the need for surgery is not considered
part of the global procedure)

Local anesthesia, such as infiltration, digital, or topical anesthesia

The surgical procedure and application of the initial dressing, cast, or
splint, including skin traction, unless excluded by the CPT TM book

Normal, uncomplicated follow-up care (follow-up days noted in the
manual).
Note: When office visits are required to treat complications or other
conditions or injuries in the follow-up period for the surgical procedure,
8-1
Chapter 8 Surgery
documentation must be submitted with the charges to support medical
necessity for the office visit. The E/M code billed is modified with -25.

Suture removal by the same practitioner or health care organization

The day after the service is rendered is considered Day 1 of the follow-up
period.
Carrier or Employer requested visits during the global period.
When a carrier or an employer requests a visit during the global period for the
purpose of changing or modifying a work restriction or to evaluate for a different job, the
carrier will prior authorize the visit and instruct the provider to bill with 99455-32 and the
carrier will pay the additional visit at $70. in accord with R 418.10401 & R 418.101501.
If the employer requests the visit, the employer should obtain the prior authorization
number from the carrier.
Anesthesia by Surgeon
When the physician performing the surgical procedure administers a regional block, the
service may be billed in addition to the surgical procedure. Procedure 01995, appended
with modifier –47, would be placed on a separate line of the HCFA 1500 claim form.
The surgeon is paid for the base units only for the procedure.
Note: Payment is not made when infiltration, digital, or topical anesthesia is
provided (Global Package, this chapter).
Surgical Supplies
Supplies and material provided by the physician (eg, sterile trays/drugs), over and
above those usually included with the office visit or other services rendered, may be
listed separately. List drugs, trays, supplies, and materials provided. Identify as 99070.
Multiple Procedures (More than one procedure performed at a single operative session)
When the same practitioner performs multiple procedures at a single operative session,
the major procedure is billed with the applicable CPTTM code and is paid at 100% of the
MAP amount. The additional or lesser procedure(s) must be billed using modifier -51.
Payment for the additional procedures will be made at 50% of the listed MAP amount.
Exceptions


When the CPTTM designates "add-on procedure" or "each additional
procedure" no modifier is appended and reimbursement is 100% of the
MAP, or the provider’s usual and customary charge, whichever is less.
When multiple injuries occur in different areas of the body, the first
Rev 2002
8-2
Chapter 8 Surgery
surgical procedure in each part of the body is reimbursed at 100% of
the MAP amount, and the remaining procedures for each part are
identified with modifier -51 and paid at 50% of the MAP amount.

Starred surgical procedures (*) do not fall under the multiple surgery rules
because the global surgery concept does not apply to starred surgical
procedures. CPT Assistant Volume 11, Issue 5, May 2001.
Separate Procedures
A procedure designated as "separate procedure" in the descriptor is commonly
performed as a component of a larger procedure and, as such, must not be paid as a
separate service. However, when a "separate procedure" is performed
independently of, and not immediately related to other services, it may be billed and
paid.
Bilateral Procedures
When a CPTTM code for a bilateral procedure is not available, report the CPTTM code for
the primary procedure on one line of the HCFA and append with modifier -50.
Reimbursement shall be 150% of the MAP amount or the provider’s usual and
customary charge, whichever is less.
Surgical Assistant
A technical surgical assistant fee may be billed for surgical procedures designated with
a "T" in the surgical section of this schedule. The operative report must document
the services of a technical assist. An assistant surgeon’s service may be billed by: a
doctor of dental surgery, a doctor of podiatry, a doctor of osteopathy, a doctor of
medicine, a physician’s assistant or a nurse with a specialty certification (nurse
practitioner or nurse midwife).
Physician Surgical Assistant: Append the procedure with modifier -80 and bill the
usual and customary charge for the primary procedure. Reimbursement will be 20%
of the MAP or the provider’s charge, whichever is less.
Certified Physician’s Assistant or Nurse Practitioner or Midwife as Surgical
Assistant: Append the procedure with modifier -81. Reimbursement will be 13% of
the MAP, or the practitioner’s usual and customary charge, whichever is less.
Note: When an office is billing for both the primary surgeon and the technical
surgical assistant, two (2) lines are used on the HCFA 1500.
Co-Surgeons
When two surgeons work together as primary surgeons performing distinct part(s) of a
single reportable procedure, each surgeon should report his/her distinct operative work
by adding Modifier -62 to the single definitive procedure. Each surgeon should report
Rev 2002
8-3
Chapter 8 Surgery
the co-surgery once using the same procedure. If additional procedure(s) (including
add-on procedure(s)) are performed during the same surgical session, separate
codes(s) may be reported without modifier -62.
Note: If a co-surgeon acts as an assistant for the remaining procedures, then
modifier -80 may be appended as appropriate.
Multiplying the MAP amount for the surgical procedure, times 125%, and then dividing
the result by 2 determines payment. Each co-surgeon receives half of the resulting
amount or 62.5% of the MAP amount.
Surgical Team
Under some circumstances highly complex procedures are carried out under the
“surgical team” concept. Each participating physician would report the basic procedure
with the addition of modifier -66.
Starred Surgical (*) Procedures
Certain services listed in the schedule are marked with a star (*) after the CPTTM code.
These are relatively small surgical procedures for which the usual global package does
not apply. Payment for the starred (*) service includes anesthesia for infiltration, digital
block, or topical application.
When the starred (*) service is performed at the time of the initial visit, and the
service is the major service rendered during the visit, an office visit will be paid when
billed with CPTTM code 99025. Example: procedure code 12001 (repair of laceration)
and procedure code 99025 (initial new patient exam) would both be paid.
When the starred (*) service is performed at the time of an initial or other visit
involving significant identifiable service(s), the appropriate E/M service is listed in
addition to the starred (*) service. Example: when an initial consult is performed and a
joint injection is also performed, it is appropriate to bill and be paid for both the consult
and the injection.
When a starred (*) service is performed at the time of a follow-up visit and the
surgical procedure constitutes the major service, the evaluation and management
service is not paid in addition to the surgical procedure.
When the starred (*) service requires hospitalization, an appropriate hospital visit is
listed, in addition to the starred (*) surgical procedure and its follow-up care.
Note: When follow-up days are listed as "0" the follow-up services shall be billed
as independent procedures.
Note: When billing starred (*) surgical procedures for injection codes into bursa,
joints, etc., the Injectable medications may be billed separately using 99070 or
Rev 2002
8-4
Chapter 8 Surgery
the appropriate J code listed in Medicare’s Level II codes. The drug shall be
reimbursed at AWP.
Wound Repair and Suture Removal
Payment for wound repair includes the evaluation, routine debridement, materials
normally required to perform the procedure and suture removal. In the rare event that
another physician, not associated with the initial physician, performs suture removal,
that physician may be paid for the office visit at the appropriate level of service and list
99070 to list the suture removal kit.
Note: The following policies for reporting wound repairs listed below were
adapted from the CPTTM manual.
Wound repairs are classified as Simple, Intermediate, or Complex.
1. Simple Repair: When a wound involves only the skin and/or superficial
tissues and requires simple suturing or use of adhesive. (When closure is
done with adhesive strips, the surgical procedure is not charged and only
the appropriate office visit is paid)
2. Intermediate Repair: When a wound involves deeper layers and requires
layer closure.
3. Complex Repair: When a wound is more complicated and requires more
than layered closure.
The repaired wound(s) should be measured and recorded in centimeters, whether
curved, angular, or stellate.
When multiple wounds of the same classification (see above) are repaired, add together
the lengths of those wounds and report them as a single repair. When multiple wounds
of more than one classification are repaired, list the more complicated as the primary
procedure, and report the less complicated as the secondary procedure by listing it
separately and adding modifier -51.
Debridement is considered a separate procedure only when gross contamination
requires prolonged cleansing, when appreciable amounts of devitalized or contaminated
tissue are removed, or when debridement is carried out separately without immediate
primary closure. (For extensive debridement of soft tissue and/or bone, see CPT TM
codes 11040-11044).
Involvement of nerves, blood vessels, and tendons: Report under appropriate system
(nervous, cardiovascular, musculoskeletal) for repair of these structures. The repair of
these associated wounds is included in the primary procedure, unless it qualifies as a
complex wound, in which case modifier -51 applies.
Rev 2002
8-5
Chapter 8 Surgery
Burns, Local Treatment
Procedure code 16000 must be used when billing for treatment of first degree burns
when no more than local treatment of the burned surface(s) is required.
Procedure codes 16010-16030 must be used only when billing for treatment of second
and third degree burns.
Note: If no burn treatment is done, then the appropriate E/M code should be
used to describe the service.
Major debridement of foreign bodies, grease, epidermis, or necrotic tissue may be billed
separately using CPTTM code 11000-11044.
In order to accurately identify the proper CPTTM code (codes 16010-16030) and
substantiate the descriptor for billing, the exact percentage of the body surface involved
and the degree of the burn must be specified in the proper section on the billing form.
Percentage of body surface burned is defined as follows:

“Small” means less than 9 percent of the body area

“Medium” means 9-18 percent of the body area (e.g., whole face or whole
extremity)

“Large” means greater than 18 percent of the body area (e.g., more than one
extremity)
Musculoskeletal System
Application of Casts and Strapping
Cast and strapping services (CPTTM codes 2900-29799) may be billed and paid when
the cast or strapping is a replacement procedure used during or after the follow-up care,
or when the cast or strapping is an initial treatment service performed without a
restorative procedure to stabilize or protect a fracture, injury or dislocation and/or to
afford comfort to a patient. CPT Assistant Volume 6, Issue 2, February 1996 discusses
when the casting codes are appropriately used.
The payment for a cast/strapping code includes the application and the removal of the
cast, splint, or strapping. Casting supplies may be billed in addition to the procedure
using 99070 or the appropriate HCPCS code, (eg, A4590).
Fracture Care
Fracture care provided during an initial visit must be billed under the appropriate CPT TM
fracture code regardless of whether the fracture is open or closed. Payment for fracture
Rev 2002
8-6
Chapter 8 Surgery
care includes the initial visit and the application and removal of the first cast or traction
device. Replacement casts provided during follow-up visits must be billed using the
appropriate CPTTM replacement casting and strapping codes (procedure codes 2900029590). When follow-up days are indicated for the surgical procedure, payment may be
made for replacement casts, but not for routine follow-up visits during the follow-up
period. If no follow-up days are indicated, office visits may be billed and paid.
Diagnostic or Therapeutic Nerve Blocks
A nerve block may be performed either for diagnostic or therapeutic purposes. The
provider will select the appropriate procedure code from the CPT TM book and bill as a
surgical procedure.
Microsurgical Procedures
The surgical microscope is employed when the surgical services are performed using
the techniques of microsurgery. Code 69990 for microsurgery is listed separately in
addition to the code for the primary procedure and is reported without modifier 51. Do not report code 69990 in addition to procedures where the use of the operating
microscope is an inclusive component or when the magnifying loupes have been used
for visual correction. Refer to the CPTTM manual for complete listing of codes where the
operating microscope is considered an inclusive component of the primary procedure.
Rev 2002
8-7
Chapter 8 Surgery Fee Schedule
Conversion Factor is $47.01 effective January 1, 2002
RVU of 0 = BR
Chapter 9
Radiology
This section stipulates only those policies and procedures that are unique to radiology
services. Additional policies and procedures that apply to all providers are listed in
Chapters 1-5 of this manual.
General Information
Radiology services include diagnostic radiology (diagnostic imaging, diagnostic
ultrasound, and nuclear medicine). Radiology services are comprised of a
professional component and a technical component. The professional component
is the physician’s interpretation of the procedure, and the technical component is the
equipment, supplies, and technician’s services used to perform the procedure. These
are discussed in greater detail later in this chapter.
Contrast Media
Complete procedures, interventional radiological procedures, or diagnostic studies
involving injection of contrast media include all usual pre-injection and post-injection
services, (e.g., necessary local anesthesia, placement of needle catheter, injection of
contrast media, supervision of the study, and interpretation of results).
When a radiology CPTTM procedure code includes the use of contrast materials in the
description, no additional payment is made for the contrast materials as they are
included in the procedure.
Low osmolar contrast material and paramagnetic contrast materials shall only be billed
when instructions indicate supplies shall be listed separately. When appropriately billed
the contrast material is reimbursed at the wholesale price and a copy of the invoice
documenting the wholesale price should be attached to the charges. A supply is billed
with the HCPCS code listed in the following table:
Code
A4641
A4644
A4645
A4646
Descriptor
Supply of radiopharmaceutical diagnostic imaging agent
Supply of low osmolar contrast material (100-199 mgs. of iodine)
Supply of low osmolar contrast material (200-299 mgs. of iodine)
Supply of low osmolar contrast material (300-399 mgs. of iodine)
X-Ray Consultation (CPTTM 76140)
CPT TM code 76140, x-ray consultation, will only be paid when there is a documented
need for the service and when performed by a radiologist or physician certified to
perform radiological services. When procedure code 76140 is billed the written report
must accompany the charges.
9-1
Chapter 9 Radiology
Note: Billing code 76140 is not appropriate in the following circumstances
because review of the x-rays is included in the E/M code:

The physician, during the course of an office visit or consultation, reviews an
x-ray that was were taken elsewhere.

The treating or consulting physician reviews x-rays at an emergency room or
hospital visit.
Billing
Radiologists are not required to enter a diagnosis code in Element 21 of the HCFA
1500.
When a CPTTM code descriptor indicates a minimum number of views, the number listed
indicates the minimum number of views required for that service, not the maximum. No
payment will be made for views in excess of the minimum number.
Billing a Total Procedure (Professional and Technical Component)
When a physician performs both the professional and technical components, bill
the appropriate CPTTM radiology code without a modifier.
Billing the Professional Component (Modifier -26)
To bill for the professional component of a procedure, such as the reading of a
radiology service provided by a hospital or diagnostic center, use the appropriate
CPTTM code and the modifier -26.
Professional services will not be reimbursed when:

The physician, during the course of an office visit or consultation reviews an
x-ray taken elsewhere.

The treating or consulting physician reviews x-rays at an emergency room or
hospital visit.
Note: Should the provider fail to add modifier -26 to a radiology
procedure provided in a hospital or other facility, payment will only be
made for the professional component.
Billing the Technical Component (Modifier -TC)
When the technical component is provided by a health care provider other than
the physician providing the professional component, the health care provider bills
9-2
Chapter 9 Radiology
for the technical component by adding modifier -TC to the applicable radiology
code.
Billing for Radiological Supervision and Interpretation
When a radiologist and a clinician work together as a team (e.g., when the clinician
injects contrast media and the radiologist supervises and interprets the procedure) each
must bill separately for services rendered.
To bill for the service rendered by the clinician in this case, use the applicable
surgical injection procedure code. Payment for the injection includes all the usual
physician services for injections (e.g., pre-and post-injection services, local anesthesia,
placement of needle or catheter, and the injection itself).
To bill for the service rendered by the radiologist, use the applicable radiology
procedure code with a descriptor that specifies "supervision and interpretation only."
Radiology Modifiers
-26
Professional Component: Radiology procedures are a combination of a
physician and technical component. When only the physician is reported use the
modifier (-26). A written report is required whenever modifier (-26) describes the
radiology service.
-TC Technical Component: Radiology procedures are a combination of a physician
and technical component. When billing for only the technical component of a
procedure, use the modifier (-TC). A hospital is not required to place modifiers on the
UB-92; however, a carrier would process the service and pay for the technical portion (TC) only in instances that
R 418.10924 applies.
When a radiologist bills for the professional portion of a radiology procedure performed
in an outpatient hospital and the procedure is being paid in accord with R 418.10916,
the radiology service shall be reimbursed by the maximum allowable payment listed in
the rules for the professional portion. The carrier shall not reduce the radiologist’s
payment by 40% as the MAP listed for the professional service is the correct payment.
9-3
Radiology Fee schedule: Fall 2000
Conversion Factor $46.56
RVU of 0.00 = BR
9-1
Chapter 10
Pathology and Laboratory
This section stipulates only those policies and procedures that are unique to pathology
and laboratory services. Additional policy and procedures that apply to all providers can
be found in Chapters 1-5 of this manual. Most of the procedure codes in the Pathology
and Laboratory Section do not have assigned RVU’s; therefore, the fees are
promulgated and published as part of the rules. Those procedures with fees are
included in this chapter of the manual as well.
Pathology and Laboratory Codes
Pathology and laboratory codes may be billed by a clinical laboratory, or in some
instances, by a physician’s office. Some pathology and laboratory services may require
interpretation by a physician. In this case, there may be a separate bill for the technical
and professional components of the procedure. The technical component is the use of
the laboratory equipment and the technician’s services, and the professional component
is the physician’s interpretation and report. When billing for the professional or the
technical component, use the appropriate modifier. When billing for the total procedure,
no modifier is required.
Pathology and laboratory codes may be billed by a hospital as either an inpatient or
outpatient service. When billed by a hospital on the UB-92, the services are identified
with the appropriate CPTTM procedures and the hospital is reimbursed by the ratio
methodology.
Modifiers
-26
Professional Component: Pathology and lab procedures are a combination of
a physician and technical component. When only the physician is reported, use the
modifier (-26).
-TC Technical Component: When billing for only the technical component of a
procedure, use the modifier (-TC)
10-1
Pathology and Laboratory Fee schedule: Fall 2000 Conversion Factor - $41.83
Procedures with RVU of 0 are BR
Lab-1
Chapter 11
Medicine
This section stipulates only those policies and procedures that are unique to the medical
services covered in this section. Additional policies and procedures that apply to all
providers are listed in Chapters 1-5 of this manual. An evaluation and management
service is referred to as an E/M service.
Manipulative Services
Chiropractic and osteopathic manipulative services, which are medicine services will be
discussed in Chapter 12 with the physical medicine services.
Audiological Function Tests
The audiometric tests (92551-92596) require the use of calibrated electronic equipment.
Other hearing tests (e.g., whisper voice or tuning fork) are considered part of the
general otorhinolaryngologic services and are not paid separately. All descriptors refer
to testing of both ears.
Psychological Services
Payment for a psychiatric diagnostic interview includes history and mental status
determination, development of a treatment plan when necessary, and the preparation of
a written report that must be submitted with the required billing form.
Psychotherapy (CPTTM codes 90804-90857) must be billed under the CPTTM code most
closely approximating the length of the session. The codes for individual therapy
services designate whether the service includes medical evaluation. Only a psychiatrist
(M.D. or D.O.) may bill for those codes that include medical evaluation (procedure
codes 90805, 90807, 90809, 90811, 90813, 90815, 90817, 90819, 90822, 90824,
90827, or 908290).
A service level adjustment factor (SLAF) is used to determine payment for
psychotherapy when a provider other than a fully licensed psychologist provides the
service(s). In those instances, the procedure codes must be identified with the
appropriate modifier identifying the provider. The MAP amount or the provider’s
usual and customary fee is then reduced by the percentage for that specialty as noted
in the following table:
Provider
Limited License Psychologist
Certified Social Worker
Licensed Professional Counselor
Modifier
-AL
-AJ
-LC
11-1
SLAF
0.85
0.85
0.85
Chapter 11 Medicine
Provider
Licensed Marriage and Family Therapist
Limited Licensed Counselor
Limited Licensed Marriage and Family Therapist
Modifier
-MF
-CS
-ML
SLAF
0.85
0.64
0.64
Note: A licensed psychologist or any of the above providers may not bill
psychiatrists’ codes that include medical evaluation of the patient.
Examples:

When a fully licensed psychologist bills procedure code 90806, no
modifier is required and the carrier payment is 100% of the MAP amount.

If a limited license psychologist bills procedure code 90806, modifier –AL
must be added and the carrier pays 85% of the MAP amount.

If a limited licensed marriage and family therapist bills procedure code
90806, modifier –ML must be added and the carrier pays 64% of the MAP
amount.
Biofeedback
Biofeedback is billed with procedure codes 90901-90911. Providers include physicians,
physical therapists, and psychologists.
Neurology and Neuromuscular Services
Neurologic services are typically consultation services and any of the five levels of
consultation may be appropriately billed in addition to the diagnostic studies.
Diagnostic studies (Nerve Conduction Tests, Electromyograms,
Electroencephalograms, etc.) may be paid in addition to the office visit or consultative
service. A diagnostic study includes both a technical component (equipment, technical
personnel, supplies, etc.) and a professional component (interpreting test results,
written report, etc). Billing without a modifier indicates that the complete service was
provided.
Electromyography (EMG)
Payment for EMG services includes the initial set of electrodes and all supplies
necessary to perform the service. The physician may be paid for a consultation or new
patient visit in addition to the EMG performed on the same day. When an EMG is
performed on the same day as a follow-up visit (established patient), payment may be
made for the visit only when documentation supports the need for the medical service in
addition to the EMG.
11-2
Chapter 11 Medicine
Nerve Conduction
A nerve conduction study is the assessment of the motor and sensory functions of a
nerve in an extremity. Nerve conduction studies may include comparison studies
when documented as medically necessary.
Physicians may be paid for both a new patient visit/consultation and nerve conduction
study performed on the same visit. When a nerve conduction study is performed on the
same day as a follow-up visit, payment for the visit may be made only when
documentation of medical necessity substantiates the need for the visit in addition to the
nerve conduction study.
Ophthalmologic Services
Only an ophthalmologist or a doctor of optometry may bill procedure codes 92002,
92004, 92012, and 92014. A doctor of optometry shall use procedure codes 9200292287 to describe services.
A medical diagnostic eye evaluation is an integral part of the ophthalmology service.
Intermediate and comprehensive ophthalmologic services include medical diagnostic
eye evaluation and services such as slit lamp examination, keratometry,
ophthalmoscopy, retinoscopy, and determination of refractive state, tonometry or motor
evaluation.
Injectable Pharmaceuticals
Payment for injection codes includes the supplies usually required to perform the
procedure, but not the medication. Injections are classified as subcutaneous,
intramuscular, or intravenous. Each of the procedure codes describing a therapeutic
injection has an assigned RVU and MAP amount.
Note: A therapeutic injection does not include the immunization procedure
codes.
When a therapeutic injection is given during an E/M service, the relative value for
providing the injection is in the payment for the E/M service and must not be billed or
paid separately. The cost of the injectable pharmaceutical may be billed using
procedure code 99070 from CPTTM or the appropriate J-Code (Medicare’s Level II
HCPCS codes). The drug is reimbursed at average wholesale price (AWP) as
determined in the current edition of Red Book.
When the injection is provided without an E/M service and only the injection will be
billed for that date of service, the injection and the medication should be listed
separately on the HCFA 1500. Report the injection by entering the appropriate CPT TM
injection code and report the medication as described in the preceding paragraph. The
11-3
Chapter 11 Medicine
payment for the injection is the MAP amount listed in this schedule. Payment for the
medication is AWP as determined by Red Book.
Anesthetic agents such as Xylocaine and Carbocaine used for local infiltration are
included in the payment for the procedure and will not be paid separately.
Modifiers
The following modifiers are used in medical services. Consult the current CPT TM
manual for a complete listing of modifiers.
-AK
-AU
- 26
-TC
-AH
-AL
-CS
-LC
-MF
-ML
Advanced practice nurse with a specialty
certification issued by the board of nursing
A certified physician’s assistant
Professional component
Technical component
Licensed psychologist
Limited license psychologist
Limited licensed counselor
Licensed professional counselor
Licensed marriage and family therapist
Limited licensed marriage and family
therapist
11-4
Medicine Fee Table: Effective Fall 2000


Red Book Determines AWP
Physical Medicine Fees and Manipulation Fees in Chapter 12
Conversion Factor is $41.83
RVU of 0.00 = BR
The following table contains the mental health procedures and reimbursements using
the adjustment factors
Medicine-1
Chapter 12
Physical Medicine and Manipulation
This section stipulates only those policies and procedures that are unique to physical
medicine and manipulative services. Additional policies and procedures that apply to all
providers are listed in Chapters 1-5 of this manual.
Manipulative Services
The initial office visit to determine the need for manipulative services is billed with the
appropriate E/M procedure code by both chiropractic and osteopathic physicians.
Ongoing manipulative services include a pre-manipulative patient evaluation. An E/M
service with ongoing manipulation is only payable when documentation supports a
significant change in signs and symptoms, or a periodic re-evaluation is required, or for
the evaluation of another work related problem. The E/M service would be reported
using modifier -25. Rationale for significant other services must be documented in the
record.
The following documentation must be submitted to the carrier:

The initial evaluation including:
1. Evaluation of function in measurable terms
2. A goal statement
3. Treatment plan
4. Physical and functional improvement in measurable terms and what
improvement should be noted if therapy were to continue

A progress report each 30 days of treatment

A discharge evaluation
Chiropractic Manipulative Treatment (CMT) is billed with procedure codes
98940-98942. Procedure code 98943, which is not in the scope of practice for
Michigan-based chiropractic physicians, or A2000 are not payable.
Osteopathic Manipulative Treatment (OMT) is billed with procedure codes
98925-98929.
12-1
Chapter 12 Physical Medicine and Manipulation
Physical Medicine Services (Procedure Codes 97000-97999)
Licensed chiropractors, physicians (M.D. ’s and D.O.’ s) physical and occupational
therapists, dentists, and podiatrists may bill and be paid for physical medicine services
(97001-97799). Physical medicine services will be paid when the therapy provided is
likely to restore function and is specific to the improvement in the patient’s condition.
When the treating provider (M.D., D.O., chiropractor, dentist, or podiatrist) provides
physical medicine services in the office, an office visit shall not be paid when the sole
purpose of the visit is to evaluate the patient’s progress in physical treatment.
Evaluation and management (E/M) services will be paid in addition to physical medicine
services (including manipulative services) only when the documentation supports a
significant other service is performed. When billing the E/M service with ongoing
physical medicine (or manipulation services), modifier -25 is appended to the E/M
code indicating a significant other service was performed other than the physical
medicine service.
Physical therapy is when physical medicine services 97001-97799 are provided by a
physical therapist and occupational therapy is when procedure codes 97001-97799 are
provided by an occupational therapist. An occupational or physical therapist must not
use the E/M codes to describe the evaluation, but would use procedure codes 9700197004.
Documentation and Policies
The following documentation must be submitted:



The initial evaluation including:
1.
A treatment plan with measurable goals
2.
Description of objective findings
3.
Documentation of limitations, if any
Progress report every 30 days documenting progress towards measurable goals
Discharge summary
Note: A periodic re-evaluation is appropriately performed and is payable
prior to the ending of the prescribed treatment or when the patient develops a
significant change in signs or symptoms. When no progress is documented
towards the goals, a re-evaluation may be done to change the treatment plan or
to discontinue treatment. Ongoing therapy should not be reimbursed unless a
treatment plan with measurable goals has been submitted to the carrier.
12-2
Chapter 12 Physical Medicine and Manipulation
Physical and occupational therapists will use evaluation procedure codes within the
physical medicine section to describe the initial evaluation. Physicians and other
providers would use the E/M service to describe the evaluation performed prior to
beginning physical medicine services.
Physical treatment services are payable on the same day as the evaluation. If
therapeutic procedures are performed on the same day as the evaluation,
appropriate modalities may also be billed.
Supervised modalities, those not requiring one-on-one contact by the provider will not
be paid unless accompanied by therapeutic procedures. (Manipulation services,
procedure codes 98925-98942 are considered therapeutic procedures in addition to
97110-97546).
Constant attendance modalities, those services requiring one-on-one contact with the
provider, may be billed and paid without being accompanied by the therapeutic
procedures. Phonophoresis is billed with procedure 97035-22 and is reimbursed the
same as 97035 plus $2.00 for the active ingredient.
Functional (Work) Capacity Assessment (FCA)
Procedure code 97750 is used to report the functional capacity testing. Total payment
for the initial testing shall not exceed 24 units or 6 hours. A copy of the report and
notes must be submitted with the bill. No more than 4 additional units shall be paid for a
re-evaluation if performed within 2 months of the initial FCA.
Work Hardening and Work Conditioning
Work hardening and work conditioning are goal-oriented therapies designed to
prepare injured workers for their return to work. Use procedure codes 97545 and
97546 to report these services. Work hardening procedures are considered by report
as no RVU is available and the carrier will reimburse at usual and customary or
reasonable, whichever is less, unless a pre-determined contractual agreement is made.
Job Site Evaluation
A carrier may request a certified occupational therapist or a registered physical therapist
to complete a job site evaluation. Reimbursement for the job site evaluation is not
based upon relative values, but is determined on a contractual basis between the carrier
and the provider. A copy of the report must be included when submitting the bill to the
carrier. The codes to bill for the job site evaluation are as follows:
Code
WC500
WC505
WC550
Work Comp Code
Job site evaluation: patient specific, initial 60 minutes
Each additional 30 minutes
Job site treatment; patient specific, initial 60 minutes
12-3
MAP
BR
BR
BR
Chapter 12 Physical Medicine and Manipulation
Code
WC555
WC600
Work Comp Code
Each additional 30 minutes
Mileage for job site evaluation or job site treatment per mile
MAP
BR
State rate
The mileage is reimbursed based upon the state approved rate that is in effect for the
date of service. The state approved rate is based on the Federal Standard Mileage
Rate (IRS determined rate). The bureau website under Publications, Travel
Reimbursement, lists past and current travel reimbursement.
Extremity Splints
Extremity splints may be prefabricated, off-the-shelf, custom-made, or custom-fit.
Prefabricated splints are billed with procedure A4570 or 99070 and are payable at AWP
plus not more than 50%.
When a therapist constructs a splint the service is described with procedure L3999. A
report must be submitted with the bill to document the description of the splint, the time
taken to construct the splint, and the charge for additional materials.
When a therapist modifies a prefabricated splint, the service would be billed with A4570
and modified with -22. A report would be included to indicate the time necessary to
modify the splint and any additional material used.
Supplies
All of the supplies (e.g., electrodes and solutions) necessary to perform any of the
physical medicine services are included in the MAP amount for the procedure.
If a provider dispenses a supply (e.g., lumbar roll, support, or cervical pillow), it shall be
billed with procedure 99070 and the carrier will pay the average wholesale price of the
supply, plus not more than a 50% mark-up. Redbook lists many average wholesale
prices for the expendable medical supplies.
Medical supplies are not routinely used in the course of physical and occupational
therapy. However, dressings that must be removed before treatment and replaced after
treatment may be billed and paid. The supplies should be billed with 99070 or the
appropriate code from Medicare’s Level II HCPCS codes. Supplies are reimbursed at
AWP plus not more than 50%.
Billing Guidelines
When billing physical therapy or occupational therapy, a physician’s prescription
should be attached to the charges.
CPTTM codes 97010-97028 are supervised modalities for the application of a modality
to one or more areas and are not billed according to units or minutes of service.
12-4
Chapter 12 Physical Medicine and Manipulation
CPTTM codes 97032-97039 are for the application of a modality to one or more areas,
requiring one-on-one patient contact by the provider, and are billed in 15-minute
increments. CPTTM codes 97110-97770 require one-on-one patient contact by the
provider and are billed in 15-minute increments.
Procedure code 97750 is used for reporting Functional Capacity Assessment
(FCA) testing and testing by means of a mechanical machine. Use of a back
machine (mechanical or computerized) is also reported using 97750.
12-5
Physical Medicine Fee Table: Effective Fall 2000
Conversion Factor is $41.83
Physical Med-1
RVU of 0.00 = BR
Chapter 13
Special Reports and Services
This section lists only those policies and procedures which are unique to special reports
and services. Providers may bill these codes as they apply.
Nurse Case Manager
If a carrier assigns a nurse case manager or rehabilitation nurse to a worker
compensation case and the nurse accompanies the worker to the physician office visit,
the provider may bill the carrier for the additional time and work involved secondary to
the nurse case manager accompanying the worker.
A nurse case manager visit may be billed in conjunction with an office visit. The provider
would bill the appropriate E/M procedure code and RN001. Both codes are reimbursed
at 100%.
Additionally, if the case manager accompanies the worker to a routine follow-up visit
during the global surgery period, the nurse case manager visit is billed with RN001.
When the visit is for routine, uncomplicated care during the global surgery period, the
E/M service is identified with 99024 and is not reimbursed separately as the visit is
included in the global surgery package.
Carrier or Employer Requested Visits for the Purpose of Job Restrictions or Revisions
When a carrier requests that a worker be seen during the global surgery period for the
purpose of reviewing a worker’s job tasks, job restrictions, or to make revisions or
adjustments to the worker’s job, then the carrier will reimburse the provider for the visit
even though the visit occurs within the global follow-up period for the surgery.
The carrier is required to prior authorize the visit and must not deny the visit. The
provider will bill the visit with procedure code 99455 using modifier 32 for carrier
mandated service. The carrier shall reimburse 99455-32 at the amount listed in Table
1501-A of the HealthCare Services Rules.
Carrier Requested Reports
If a carrier requests the provider to generate a report that is over and above the reports
contained within the medical record, then the carrier must reimburse the provider for
that report. The provider will bill the report with procedure code 99199 using modifier 32
for carrier requested service.
The carrier will reimburse the provider at $25.00 per page if the report is 3 pages or
less. If the report is more extensive then reimbursement shall be considered “by
13-1
Chapter 13 Special Reports and Services
report.” Because the rules do not prohibit the carrier and provider from entering into a
contractual agreement this report could also be reimbursed contractually.
Copies of Reports and Records
Providers are required to include certain copies of the medical record (refer to
R 418.10113, R 418.10212, and R 418.10901(3)) when submitting claims and may not
charge the carrier for those required reports. When the carrier (or the carrier’s agent)
requests additional medical records pertaining to a specific date of injury or duplicate
copies of the medical record, the provider may bill for those records. The carrier will
reimburse the provider for the additional records or duplicate copies as follows:
 25 cents per page, plus
 The actual cost of mailing the records, plus
 A handling fee outlined in the following table:
0-30 minutes
31-60 minutes
Each additional 30 minute increment
$3.50
$7.00
$3.50
Medical records pertaining to a specific date of injury may be requested by:


A carrier or their agent (attorney or review company)
An injured worker or their agent (attorney)
Note: The provider may bill their usual and customary charge for records
that do not pertain to a specific date of injury (other than the case record).
Services Occurring "After Hours"
When an office service occurs after a provider’s normal business hours, procedure codes
99050-99058 may be billed. Payment shall not be made for these codes when the service
occurs during the provider’s normal hours of business (e.g., emergency room or clinics that are
open 16-24 hours of the day).
01999-PA
90471
90472
99000
99025
99050
99052
99054
99199
99199-32
WC700
99455-32
RN001-32
Table 1501-A from the Health Care Services Rules in R 418.101501
Patient Controlled Analgesia (See R 418.10915)
$137.00
Administration of a single or combination vaccine
$7.50
Administration of two or more vaccines or toxoid
$5.00
Handling or conveyance of specimen
$5.00
Initial new patient exam performed with a starred surgical procedure
$55.00
After hour office service Monday-Friday (R 418.10202)
$5.00
Services between 10:00PM and 8:00AM
$5.00
Weekend, holiday after hour office service
$12.00
Carrier arranged missed appointment. (See R 418.10111)
BR
Carrier or requested report, per page (See R 418.10114)
$25.00
Prescription Drug dispense fee (R 418.10912(4)
$4.00
Carrier requested visit for job evaluation (R 418.10404)
$70.00
Rehabilitation or case manager visit (See R 418.10121)
$25.00
13-2
Chapter 13 Special Reports and Services
13-3
Chapter 14
Ancillary Services
This section contains information specific to ancillary services. The services cited in this
chapter (with the exception of the L-Code procedures) are considered "by report" and
do not have assigned fees. Refer to Medicare’s National Level II HCPCS for a
complete listing of all ancillary procedures. Only the L-Code procedures that have
assigned fees will be published in this manual. In addition, this section also includes
specific workers’ compensation codes for billing home health services.
The following services are considered ancillary services. The ancillary service(s)
provided to treat a covered work injury or illness is covered under the Workers’
Disability Compensation Act and the Health Care Services Rules. A complete listing of
all of the procedure codes used for the following services may be found in Medicare’s
National Level II HCPCS:

Ambulance Services (Codes A0021-A0999)

Expendable Medical and Surgical Supplies (A4000-A8999)

Dental Procedures (D0120-D9999)
Note: Omitting the “D” preceding the procedure may also be seen when dental
procedure codes are billed.

Durable Medical Equipment (E0100-E9999)

Orthotic and Prosthetic Procedures (L0000-L9999)

Vision Services (V0000-V2999)

Hearing Services (V5000-V5999)

Home Health Services (S9122-S9425, S9524-S9555, or G0151-G0156)
The only procedures that will be listed in this manual are the orthotic and prosthetic
codes, the L-Code procedures that have set fees. Refer to HCPCS, Medicare’s Level II
codes for a complete listing of all other procedures.
The durable medical and expendable medical supplies are reimbursed at average
wholesale price (AWP), plus not more than 50%. When billing durable medical
supplies, a copy of the prescription is attached to the bill.
14-1
Chapter 14 Ancillary Services
There are no set fees for the ancillary services and with exception of dental services,
the following services are practitioner services, billed on the HCFA 1500 claim form.
Dental services are billed using the Standard American Dental claim form.
All services noted below are reimbursed “by report”, BR. This means the service is
reimbursed at either the practitioner’s usual and customary charge or reasonable,
whichever is less. Definitions for usual and customary are found in R 418.10109.
 Ambulance services
 Dental services
 Home health services
 Hearing services
 Vision services
“Reasonable amount” is defined as a payment based upon the amount generally paid in
the state for a particular procedure code. Generally, data from all other payers across
the board is considered when determining reasonable payment.
“Usual and Customary charge” means a particular provider’s average charge for a
procedure to all payment sources, calculated based on data beginning January 1, 1995.
Home Health Services
The home health services for worker’ compensation in Michigan are billed on the UB-92
claim form submitted to the carrier using procedure codes from either the S or G series
of procedure codes from HCPCS, Medicare’ s Level II as adopted by reference in
R 418.10107
If a home health agency bills for therapy services by an occupational therapist, a
physical therapist, or a speech and language pathologist, the agency will use the
appropriate HCPCS coding to describe the therapy services.
A home health agency may bill supplies using the appropriate supply code from the
HCPCS Medicare Level II book, adopted by reference in R 418.10107. Progress notes
will be submitted with the charges to document the services and supplies on the bill.
There are no set fees for the home health services. Any of the practitioner services
rendered in the home are by report and are reimbursed at either the provider’s usual
and customary charge as defined in the rules or reasonable, whichever is less. Therapy
services may be reimbursed at a per diem rate when the code is described as a per
diem service or by the total time of the service if the procedure billed indicates it is timebased. Per-diem would be a daily rate or visit. Supplies dispensed as part of the home
care service are reimbursed as in the next paragraph.
Supplies
Expendable medical supplies and durable medical equipment are paid at the average
Rev 2002
14-2
Chapter 14 Ancillary Services
wholesale price, plus a markup of not more than 50% above average wholesale price.
The Redbook, as adopted in the Health Care Services Rules, R 418.10107, lists many
of the wholesale prices for the expendable medical supplies.
Orthotic and Prosthetic Services
The treating practitioner prescribes orthotic or prosthetic services. When these services
are billed, a copy of the prescription is included with the charges. Orthotic equipment or
orthosis means an orthopedic apparatus or device that is designed to support, align,
prevent, or correct deformities of, or improve the function of, a moveable body part. An
orthotist is a practitioner skilled in the design, fabrication, and fitting of an orthosis or
orthotic equipment. Orthotic equipment may be any of the following:


Custom-fit which means the device is fitted to a specific patient.
Custom-fabricated which mean the device is made for a specific patient from
individualized measurements, pattern, or both.

Non-custom supply means that the device is prefabricated, off-the-shelf, requires
little or no fitting, and minimal instruction. A non-custom supply is intended for
short-term use and does not include prosthetic procedures.
Prosthesis means an artificial limb or substitute for a missing body part. A prosthesis is
constructed by a prosthetist, a practitioner who is skilled in the design, fabrication, and
fitting of artificial limbs or prosthesis.
An orthotic or prosthetic procedure code that does not have an assigned fee is
considered “by report” and requires a written description accompanying the charges on
the HCFA 1500 claim form. The report shall include:




Date of service
A description of the service provided
The time involved
The charge for materials/components
Rev 2002
14-3
L-Code, Orthotic and Prosthetics Fee Table
L-Code procedures not listed on this table are BR
L0120
L0130
L0140
L0150
L0160
L0170
L0172
L0174
L0180
L0190
L0200
L0210
L0220
L0300
L0310
L0315
LO317
LO320
L0330
L0340
L0350
L0360
L0370
L0380
L0390
L0400
L0410
L0420
L0430
L0440
L0500
L0510
L0515
L0520
L0530
L0540
L0550
L0560
L0565
L0600
L0610
ORTHOTIC AND PROSTHETIC PROCEDURES (L-CODES)
MAP
Cervical, flexible, nonadjustable (foam collar)
Cervical, flexible, thermoplastic collar, molded to patient
Cervical, semi-rigid, adjustable (plastic collar)
Cervical, semi-rigid, adjustable molded chin cup
Cervical, semi-rigid, wire frame occipital/mandibular support
Cervical collar, molded to patient model
Cervical collar, semi-rigid, thermoplastic foam, two-piece
Cervical collar, semi-rigid, thermoplastic foam, two-piece with thoracic extension
Cervical, multiple post collar, occipital/mandibular supports, adjustable
Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical
bars
Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical
bars,
Thoracic rib belt, custom fitted
Thoracic rib belt, custom fabricated
TLSO, flexible (dorso-lumbar surgical support), custom fitted
TLSO, flexible (dorso-lumbar surgical support), custom fabricated
TLSO, flexible (dorso-lumbar surgical support), elastic type, with rigid posterior
panel
TLSO, flexible (dorso-lumbar surgical support), hyperextension, elastic type, with
TLSO, anterior-posterior control (Taylor type), with apron front
TLSO, anterior-posterior-lateral control (Knight-Taylor type) with apron front
TLSO, anterior-posterior-lateral-rotary control (Arnold, Magnuson, Steindler
types),
TLSO, anterior-posterior-lateral-rotary control, flexion compression jacket,
custom
TLSO, anterior-posterior-lateral-rotary control, flexion compression jacket molded
TLSO, anterior-posterior-lateral-rotary control, hyperextension (Jewett, Lennox,
Baker,
TLSO, anterior-posterior-lateral-rotary control, with extensions
TLSO, anterior-posterior-lateral control molded to patient model
TLSO, anterior-posterior-lateral control molded to patient model, with interface
material
TLSO, anterior-posterior-lateral control, two-piece construction, molded to patient
model
TLSO, anterior-posterior-lateral control, two-piece construction, molded to patient
TLSO, anterior-posterior-lateral control, with interface material, custom fitted
TLSO, anterior-posterior-lateral control, with overlapping front section, spring
steel
LSO, flexible (lumbo-sacral surgical support), custom fitted
LSO, flexible (lumbo-sacral surgical support), custom fabricated
LSO, flexible (lumbo-sacral surgical support), elastic type, with rigid posterior
panel
LSO, anterior-posterior-lateral control (Knight, Wilcox types), with apron front
LSO, anterior-posterior control (Macausland type), with apron front
LSO, lumbar flexion (Williams flexion type)
LSO, anterior-posterior-lateral control, molded to patient model
LSO, anterior-posterior-lateral control, molded to patient model, with interface
material
LSO, anterior-posterior-lateral control, custom fitted
Sacroiliac, flexible (sacroiliac surgical support), custom fitted
Sacroiliac, flexible (sacroiliac surgical support), custom fabricated
$17.29
$117.02
$42.00
$74.60
$119.82
$796.31
$110.00
$194.07
$314.44
$407.89
L Code-1
$430.12
$28.85
$90.00
$124.59
$242.46
$213.27
$255.89
$336.00
$476.12
$567.22
$696.40
$1,551.72
$349.60
$614.95
$1,400.30
$1,498.32
$1,626.40
$1,886.09
$1,062.50
$899.60
$99.00
$214.00
$176.00
$358.03
$359.95
$387.68
$1,273.00
$1,590.56
$902.84
$60.09
$224.46
L-Code, Orthotic and Prosthetics Fee Table
L-Code procedures not listed on this table are BR
L0620
L0700
L0710
L0810
L0820
L0830
L0860
L0900
L0910
L0920
L0930
L0940
L0950
L0960
L0970
L0972
L0974
L0976
L0978
L0980
L0982
L0984
L1000
L1010
L1020
L1025
L1030
L1040
L1050
L1060
L1070
L1080
L1085
L1090
L1100
L1110
L1120
L1200
L1210
L1220
L1230
L1240
L1250
L1260
L1270
L1280
L1290
L1300
L1310
L1499
L1500
ORTHOTIC AND PROSTHETIC PROCEDURES (L-CODES)
MAP
Sacroiliac, semi-rigid, (Goldthwaite, Osgood types), with apron front
CTLSO, anterior-posterior-lateral control, molded to patient model, (Minerva
type)
CTLSO, anterior-posterior-lateral-control, molded to patient model, with interface
Halo procedure, cervical halo incorporated into jacket vest
Halo procedure, cervical halo incorporated into plaster body jacket
Halo procedure, cervical halo incorporated into Milwaukee type orthosis
Addition to halo procedure, magnetic resonance image compatible system
Torso support, ptosis support, custom fitted
Torso support, ptosis support, custom fabricated
Torso support, pendulous abdomen support, custom fitted
Torso support, pendulous abdomen support, custom fabricated
Torso support, postsurgical support, custom fitted
Torso support, postsurgical support, custom fabricated
Torso support, postsurgical support, pads for postsurgical support
TLSO, corset front
LSO, corset front
TLSO, full corset
LSO, full corset
Axillary crutch extension
Peroneal straps, pair
Stocking supporter grips, set of four (4)
Protective body sock, each
CTLSO, inclusive of furnishing initial orthosis, including model
Addition to CTLSO or scoliosis orthosis, axilla sling
Addition to CTLSO or scoliosis orthosis, kyphosis pad
Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating
Addition to CTLSO or scoliosis orthosis, lumbar bolster pad
Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad
Addition to CTLSO or scoliosis orthosis, sternal pad
Addition to CTLSO or scoliosis orthosis, thoracic pad
Addition to CTLSO or scoliosis orthosis, trapezius sling
Addition to CTLSO or scoliosis orthosis, outrigger
Addition to CTLSO or scoliosis orthosis, outrigger, bilateral w/ vertical extensions
Addition to CTLSO or scoliosis orthosis, lumbar sling
Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather
Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather,
Addition to CTLSO, scoliosis orthosis, cover for upright, each
TLSO, inclusive of furnishing initial orthosis only
Addition to TLSO (low profile), lateral thoracic extension
Addition to TLSO (low profile), anterior thoracic extension
Addition to TLSO (low profile), Milwaukee type superstructure
Addition to TLSO (low profile), lumbar derotation pad
Addition to TLSO (low profile), anterior ASIS pad
Addition to TLSO (low profile), anterior thoracic derotation pad
Addition to TLSO (low profile), abdominal pad
Addition to TLSO (low profile), rib gusset (elastic), each
Addition to TLSO (low profile), lateral trochanteric pad
Other scoliosis procedure, body jacket molded to patient model
Other scoliosis procedure, postoperative body jacket
Spinal orthosis, not otherwise classisfied
THKAO, mobility frame (Newington, Parapodium types)
$367.86
$1,779.93
L-Code-2
$1,882.90
$2,371.87
$1,876.79
$2,829.65
$960.00
$104.34
$302.09
$110.60
$328.72
$103.04
$299.10
$60.01
$99.30
$89.42
$155.56
$138.95
$167.24
$15.17
$14.15
$47.18
$1,763.98
$58.31
$75.11
$108.35
$55.27
$67.79
$72.34
$83.09
$78.18
$48.08
$133.74
$79.64
$138.17
$221.90
$34.51
$1,424.25
$227.34
$192.48
$493.91
$67.46
$62.77
$65.74
$67.32
$74.95
$68.29
$1,451.36
$1,493.46
BR
$1,650.36
L-Code, Orthotic and Prosthetics Fee Table
L-Code procedures not listed on this table are BR
L1510
L1520
L1685
L1686
L1800
L1810
L1815
L1820
L1825
L1830
L1832
L1834
L1840
L1844
L1845
L1850
L1855
L1858
L1860
L1870
L1880
L1900
L1902
L1904
L1906
L1910
L1920
L1930
L1940
L1945
L1950
L1960
L1970
L1980
L1990
L2000
L2010
L2020
L2030
L2036
L2037
L2038
L2040
L2050
L2060
L2070
L2080
L2090
L2102
L2104
L2106
L2108
ORTHOTIC AND PROSTHETIC PROCEDURES (L-CODES)
MAP
THKAO, standing frame
THKAO, swivel walker
HO, abduction control of hip joint, postop. hip abduction type, custom fabricated
HO, abduction control of hip joint, postop. hip abduction type, custom fitted
KO, elastic with stays, prefabricated, includes fitting and adjustment
KO, elastic with joints, prefabricated, includes fitting and adjustment
KO, elastic or other elastic type material with condylar pad(s)
KO, elastic or other elastic type material with condylar pads and joints, prefab
KO, elastic knee cap, prefabricated
KO, immobilizer, canvas longitudinal, prefabricated
KO, adjustable knee joints, positional orthosis, rigid support, prefab incl fitting
KO, without knee joint, rigid, custom fabricated
KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated
KO, single upright, thigh and calf, with adjustable flexion and extension joint,
KO, double upright, thigh and calf, with adjustable flexion and extension joint,
KO, Swedish type, prefabricated
KO, molded plastic, thigh and calf sections, with double upright knee joints,
KO, molded plastic, polycentric knee joints, pneumatic knee pads (CTI)
KO, modification of supracondylar prosthetic socket, custom fabricated (SK)
KO, double upright, thigh and calf lacers, with knee joints, custom fabricated
KO, double upright, nonmolded thigh and calf cuffs/lacers with knee joints
AFO, spring wire, dorsiflexion assist calf band, custom fabricated
AFO, ankle gauntlet, prefabricated, includes fitting and adjustment
AFO, molded ankle guantlet, custom fabricated
AFO, multi-ligamentus ankle support, prefabricated
AFO, posterior, single bar, clasp attachment to shoe counter, prefabricated
AFO, single upright with static or adjustable stop (Phelps or Perlstein type)
AFO, plastic, prefabricated
AFO, plastic, custom fabricated
AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction)
AFO, spiral, (IRM type), plastic, custom fabricated
AFO, posterior solid ankle, plastic, custom fabricated
AFO, plastic, with ankle joint, custom fabricated
AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single
AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double
KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands
KAFO, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single
KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cu
KAFO, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs (double
KAFO, full plastic, double upright, free knee, custom fabricated
KAFO, full plastic, single upright, free knee, custom fabricated
KAFO, full plastic, without knee joint, multiaxis ankle, custom fabricated
HKAFO, torsion control, bilateral rotation straps, pelvic band/belt
HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt
HKAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic
HKAFO, torsion control, unilateral rotation straps, pelvic band/belt
HKAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt
HKAFO, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic
AFO, fracture orthosis, tibial fracture cast orthosis, plaster type casting material,
AFO, fracture orthosis, tibial fracture cast orthosis, synthetic type casting material
AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting
AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated
$828.93
$1,486.64
$1,033.49
$653.04
$43.34
$81.00
$63.13
$103.00
$35.83
$57.01
$480.05
$674.46
$798.89
$734.88
$583.78
$187.57
$954.77
$1,221.93
$1,383.48
$909.28
$550.82
$234.40
$52.02
$333.00
$86.17
$174.27
$286.29
$175.57
$429.68
$1,145.70
$647.18
$530.36
$618.24
$318.88
$459.09
$881.27
$803.35
$1,132.33
$880.19
$2,022.35
$1,447.16
$1,024.83
$154.26
$413.88
$504.44
$116.84
$312.50
$380.99
$521.09
$619.81
$747.33
$1,170.03
L-Code-3
L-Code, Orthotic and Prosthetics Fee Table
L-Code procedures not listed on this table are BR
L2112
L2114
L2116
L2122
L2124
L2126
L2128
L2132
L2134
L2136
L2180
L2182
L2184
L2186
L2188
L2190
L2192
L2200
L2210
L2220
L2230
L2240
L2250
L2260
L2265
L2270
L2275
L2280
L2300
L2310
L2320
L2330
L2335
L2340
L2350
L2360
L2370
L2375
L2380
L2385
L2390
L2395
L2397
L2405
L2415
L2425
L2435
L2492
L2500
L2510
L2520
L2525
ORTHOTIC AND PROSTHETIC PROCEDURES (L-CODES)
MAP
AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated
AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated
AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated
KAFO, fracture orthosis, femoral fracture cast orthosis, plaster type casting
KAFO, fracture orthosis, femoral fracture cast orthosis, synthetic type casting
KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type cast.
KAFO, fracture orthosis, femoral fracture cast orthosis, custom fabricated
KAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated
KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid prefabricated
KAFO, fracture orthosis, femoral fracture cast orthosis, rigid prefabricated
Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints
Addition to lower extremity fracture orthosis, drop lock knee joint
Addition to lower extremity fracture orthosis, limited motion knee joint
Add. to lower extremity fracture orthosis, adjustable motion knee joint, Lerman
Addition to lower extremity fracture orthosis, quadrilateral brim
Addition to lower extremity fracture orthosis, waist belt
Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange,
Addition to lower extremity, limited ankle motion, each joint
Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint
Add. to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint
Addition to lower extremity, split flat caliper stirrups and plate attachment
Addition to lower extremity, round caliper and plate attachment
Add. to lower extremity, foot plate, molded to patient model, stirrup attachment
Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)
Addition to lower extremity, long tongue stirrup
Addition to lower extremity, varus/valgus correction ("T") strap, padded/lined or
Add. to lower extremity, varus/valgus correction, plastic modification, padded/line
Addition to lower extremity, molded inner boot
Addition to lower extremity, abduction bar (bilateral hip involvement), jointed
Addition to lower extremity, abduction bar, straight
Addition to lower extremity, nonmolded lacer
Addition to lower extremity, lacer molded to patient model
Addition to lower extremity, anterior swing band
Addition to lower extremity, pre-tibial shell, molded to patient model
Add. to lower extremity, prosthetic type, (BK) socket, molded to patient model,
Addition to lower extremity, extended steel shank
Addition to lower extremity, Patten bottom
Addition to lower extremity, torsion control, ankle joint and half solid stirrup
Addition to lower extremity, torsion control, straight knee joint, each joint
Addition to lower extremity, straight knee joint, heavy duty, each joint
Addition to lower extremity, offset knee joint, each joint
Addition to lower extremity, offset knee joint, heavy duty, each joint
Addition to lower extremity orthosis, suspension sleeve
Addition to knee joint, drop lock, each joint
Addition to knee joint, cam lock (Swiss, French, Bail types), each joint
Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint
Addition to knee joint, polycentric joint, each joint
Addition to knee joint, lift loop for drop lock ring
Add. to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring
Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to
Add. to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fitted
Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L
$304.03
$440.38
$537.16
$891.10
$992.94
$1,356.79
$1,498.50
$525.66
$803.12
$878.87
$101.75
$79.63
$107.63
$130.80
$260.22
$59.45
$309.80
$41.30
$58.40
$71.16
$66.67
$72.66
$308.74
$174.17
$102.31
$46.67
$103.91
$393.43
$233.93
$106.88
$178.76
$341.16
$197.38
$388.32
$774.19
$44.96
$223.04
$99.17
$106.97
$116.38
$95.11
$101.95
$87.81
$44.22
$159.56
$158.17
$143.80
$88.60
$274.10
$631.12
$374.57
$873.78
L-Code-4
L-Code, Orthotic and Prosthetics Fee Table
L-Code procedures not listed on this table are BR
L2526
L2530
L2540
L2550
L2570
L2580
L2600
L2610
L2620
L2622
L2624
L2627
L2628
L2630
L2640
L2650
L2660
L2670
L2680
L2750
L2760
L2770
L2780
L2785
L2795
L2800
L2810
L2820
L2830
L2840
L2850
L2999
L3000
L3001
L3002
L3003
L3010
L3020
L3030
L3040
L3050
L3060
L3070
L3080
L3090
L3100
L3150
L3215
L3216
L3217
L3218
L3219
ORTHOTIC AND PROSTHETIC PROCEDURES (L-CODES)
MAP
Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L
Addition to lower extremity, thigh/weight bearing, lacer, nonmolded
Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model
Addition to lower extremity, thigh/weight bearing, high roll cuff
Addition to lower extremity, pelvic control, hip joint, Clevis type, two position
Addition to lower extremity, pelvic control, pelvic sling
Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust
Addition to lower extremity, pelvic control, hip joint, Clevis, or thrust
Addition to lower extremity, pelvic control, hip joint, heavy-duty, each
Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each
Addition to lower extremity, pelvic control, hip joint, adjustable flexion,
Addition to lower extremity, pelvic control, plastic, molded to patient model,
Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint
Addition to lower extremity, pelvic control, band and belt, unilateral
Addition to lower extremity, pelvic control, band and belt, bilateral
Addition to lower extremity, pelvic and thoracic control, gluteal pad, each
Addition to lower extremity, thoracic control, thoracic band
Addition to lower extremity, thoracic control, paraspinal uprights
Addition to lower extremity, thoracic control, lateral support uprights
Addition to lower extremity orthosis, plating chrome or nickel, per bar
Addition to lower extremity orthosis, extension, per extension, per bar
Addition to lower extremity orthosis, any material, per bar or joint
Addition to lower extremity orthosis, non-corrosive finish, per bar
Addition to lower extremity orthosis, drop lock retainer, each
Addition to lower extremity orthosis, knee control, full kneecap
Addition to lower extremity orthosis, knee control, kneecap, medial or lateral pull
Addition to lower extremity orthosis, knee control, condylar pad
Addition to lower extremity orthosis, soft interface for molded plastic, below knee
Addition to lower extremity orthosis, soft interface for molded plastic, above knee
Addition to lower extremity orthosis, tibial length sock, fracture or equal, each
Addition to lower extremity orthosis, femoral length sock, fracture or equal, each
Unlisted procedures for lower extremity orthoses
Foot insert, removable, molded to patient model, "UCB" type, Berkeley shell, ea
Foot insert, removable, molded to patient model, Spenco, each
Foot insert, removable, molded to patient model, Plastazote or equal, each
Foot insert, removable, molded to patient model, silicone gel, each
Foot insert, removable, molded to patient model, longitudinal arch support, each
Foot insert, removable, molded to patient model, longitudinal/metatarsal support,
Foot insert, removable, formed to patient foot, each
Foot, arch support, removable, premolded, longitudinal, each
Foot, arch support, removable, premolded, metatarsal, each
Foot, arch support, removable, premolded, longitudinal/metatarsal, each
Foot, arch support, nonremovable, attached to shoe, longitudinal, each
Foot, arch support, nonremovable, attached to shoe, metatarsal, each
Foot, arch support, nonremovable, attached to shoe, longitudinal/metatarsal, ea
Hallus-Valgus night dynamic splint
Foot, abduction rotation bar, without shoes
Orthopedic footwear, woman's shoes, oxford
Orthopedic footwear, woman's shoes, depth inlay
Orthopedic footwear, woman's shoes, hightop, depth inlay
Orthopedic footwear, woman's surgical boot, each
Orthopedic footwear, man's shoes, oxford
$595.12
$204.14
$367.33
$249.53
$413.84
$403.24
$178.44
$211.00
$232.31
$266.44
$287.71
$1,489.46
$1,455.67
$215.15
$291.98
$104.27
$161.94
$148.21
$135.96
$72.62
$52.79
$53.64
$58.80
$27.54
$57.13
$92.00
$67.86
$75.46
$81.62
$30.06
$42.15
BR
$170.00
BR
$99.00
$99.00
$135.00
$99.00
BR
BR
BR
BR
BR
BR
BR
BR
BR
$94.18
$108.00
$127.00
$87.00
$102.87
L-Code-5
L-Code, Orthotic and Prosthetics Fee Table
L-Code procedures not listed on this table are BR
L3221
L3222
L3223
L3230
L3250
L3251
L3252
L3253
L3254
L3257
L3260
L3265
L3300
L3310
L3320
L3330
L3332
L3334
L3340
L3350
L3360
L3370
L3380
L3390
L3400
L3410
L3420
L3430
L3440
L3500
L3510
L3520
L3530
L3540
L3550
L3560
L3570
L3580
L3590
L3595
L3650
L3660
L3670
L3700
L3710
L3720
L3730
L3740
L3800
L3805
L3810
L3815
ORTHOTIC AND PROSTHETIC PROCEDURES (L-CODES)
MAP
Orthopedic footwear, man's shoes, depth inlay
Orthopedic footwear, man's shoes, hightop, depth inlay
Orthopedic footwear, man's surgical boot, each
Orthopedic footwear, custom shoes, depth inlay
Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic
Foot, shoe molded to patient model, silicone shoe, each
Foot, shoe molded to patient model, Plastazote (or similar), custom fabricated,
Foot, molded shoe Plastazote (or similar), custom fitted, each
Nonstandard size or width
Orthopedic footwear, additional charge for split size
Ambulatory surgical boot, each
Plastazote sandal, each
Lift, elevation, heel, tapered to metatarsals, per inch
Lift, elevation, heel and sole, neoprene, per inch
Lift, elevation, heel and sole, cork, per inch
Lift, elevation, metal extension (skate)
Lift, elevation, inside shoe, tapered, up to one-half inch
Lift, elevation, heel, per inch
Heel wedge, SACH
Heel wedge
Sole wedge, outside sole
Sole wedge, between sole
Clubfoot wedge
Outflare wedge
Metatarsal bar wedge, rocker
Metatarsal bar wedge, between sole
Full sole and heel wedge, between sole
Heel, counter, plastic reinforced
Heel, counter, leather reinforced
Miscellaneous shoe addition, insole, leather
Miscellaneous shoe addition, insole, rubber
Miscellaneous shoe addition, insole, felt covered with leather
Miscellaneous shoe addition, sole, half
Miscellaneous shoe addition, sole, full
Miscellaneous shoe addition, toe tap, standard
Miscellaneous shoe addition, toe tap, horseshoe
Miscellaneous shoe addition, special extension to instep (leather with eyelets)
Miscellaneous shoe addition, convert instep to Velcro closure
Miscellaneous shoe addition, convert firm shoe counter to soft counter
Miscellaneous shoe addition, March bar
SO, figure of eight design abduction restrainer
SO, figure of eight design abduction restrainer, canvas and webbing
SO, acromio/clavicular (canvas and webbing type)
EO, elastic with stays
EO, elastic with metal joints
EO, double upright with forearm/arm cuffs, free motion
EO, double upright with forearm/arm cuffs, extension/flexion assist
EO, double upright with forearm/arm cuffs, adjustable position lock with active
WHFO, short opponens, no attachments
WHFO, long opponens, no attachment
WHFO, addition to short and long opponens, thumb abduction ("C") bar
WHFO, addition to short and long opponens, second M.P. abduction assist
$120.00
$150.00
$91.00
$425.00
$381.00
$450.00
$300.00
$90.00
$38.00
$180.00
$60.00
$35.00
$42.00
$40.00
BR
$275.00
$18.00
$25.00
$70.00
$13.00
$15.00
$22.00
$32.00
$15.00
$56.00
$64.00
$32.00
$44.00
$35.00
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$37.82
$65.54
$72.11
$44.51
$78.83
$556.10
$766.44
$908.66
$140.00
$256.00
$55.09
$51.16
L-Code-6
L-Code, Orthotic and Prosthetics Fee Table
L-Code procedures not listed on this table are BR
L3820
L3825
L3830
L3835
L3840
L3845
L3850
L3855
L3860
L3900
L3901
L3902
L3904
L3906
L3907
L3908
L3910
L3912
L3914
L3916
L3918
L3920
L3922
L3924
L3926
L3928
L3930
L3932
L3934
L3936
L3938
L3940
L3942
L3944
L3946
L3948
L3950
L3952
L3954
L3960
L3962
L3963
L3964
L3965
L3966
L3968
L3969
L3970
L3972
L3974
L3980
L3982
ORTHOTIC AND PROSTHETIC PROCEDURES (L-CODES)
MAP
WHFO, addition to short and long opponens, I.P. extension assist, with M.P.
WHFO, addition to short and long opponens, M.P. extension stop
WHFO, addition to short and long opponens, M.P. extension assist
WHFO, addition to short and long opponens, M.P. spring extension assist
WHFO, addition to short and long opponens, spring swivel thumb
WHFO, addition to short and long opponens, thumb I.P. extension assist, w M.P.
WHFO, addition to short and long opponens, action wrist, with dorsiflexion assist
WHFO, addition to short and long opponens, adjustable M.P. flexion control
WHFO, add. to short and long opponens, adjustable M.P. flexion control & I.P.
WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/
WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion
WHFO, external powered, compressed gas
WHFO, external powered, electric
WHFO, wrist gauntlet, custom fabricated
WHFO, wrist gauntlet with thumb spica, custom fabricated
WHFO, wrist extension control cock-up, prefabricated
WHFO, Swanson design
WHFO, flexion glove with elastic finger control
WHFO, wrist extension cock-up, prefabricated
WHFO, wrist extension cock-up, with outrigger, prefabricated
WHFO, knuckle bender, prefabricated
WHFO, knuckle bender, with outrigger, prefabricated
WHFO, knuckle bender, two segment to flex joints, prefabricated
WHFO, Oppenheimer, prefabricated
WHFO, Thomas suspension, prefabricated
WHFO, finger extension, with clock spring, prefabricated
WHFO, finger extension, with wrist support, prefabricated
WHFO, safety pin, spring wire, prefabricated
WHFO, safety pin, modified, prefabricated
WHFO, Palmer, prefabricated
WHFO, dorsal wrist, prefabricated
WHFO, dorsal wrist, with outrigger attachment, prefabricated
WHFO, reverse knuckle bender, prefabricated
WHFO, reverse knuckle bender, with outrigger, prefabricated
WHFO, composite elastic, prefabricated
WHFO, finger knuckle bender, prefabricated
WHFO, combination Oppenheimer, with knuckle bender and two attachments
WHFO, combination Oppenheimer, with reverse knuckle and two attachments
WHFO, spreading hand, prefabricated
SEWHO, abduction positioning, airplane design, prefabricated
SEWHO, abduction positioning, Erbs palsy design, prefabricated
SEWHO, molded shoulder, arm, forearm, and wrist with articulating elbow joint
SEO, mobile arm support attached to wheelchair, balanced, adj. prefabricated
SEO, mobile arm support attached to wheelchair, balanced, adj. prefabricated
SEO, mobile arm support attached to wheelchair, balanced, recline prefabricated
SEO, mobile arm support attached to wheelchair, balanced and fitted to patient,
SEO, mobile arm support, monosuspension arm and hand support, overhead
SEO, addition to mobile arm support, elevating proximal arm
SEO, addition to mobile arm support, offset or lateral rocker arm with elastic
SEO, addition to mobile arm support, supinator
Upper extremity fracture orthosis, humeral, prefabricated
Upper extremity fracture orthosis, radius/ulnar, prefabricated
$87.86
$55.14
$71.98
$78.02
$53.45
$69.02
$98.59
$99.38
$136.03
$1,396.48
$1,481.20
$2,137.19
$2,354.94
$384.00
$406.00
$38.21
$253.61
$69.00
$62.00
$109.00
$64.00
$90.00
$75.02
$88.95
$71.96
$43.89
$50.94
$38.12
$40.91
$75.73
$74.25
$83.41
$62.14
$78.52
$59.28
$46.85
$126.68
$141.50
$77.63
$505.85
$457.52
$1,063.83
$501.52
$772.40
$613.07
$713.05
$563.81
$193.93
$178.22
$109.98
$197.13
$238.05
L-Code-7
L-Code, Orthotic and Prosthetics Fee Table
L-Code procedures not listed on this table are BR
L3984
L3985
L3986
L3995
L3999
L4000
L4010
L4020
L4030
L4040
L4045
L4050
L4055
L4060
L4070
L4080
L4090
L4100
L4110
L4130
L4210
L4350
L4360
L4370
L4380
L5000
L5010
L5020
L5050
L5060
L5100
L5105
L5150
L5160
L5200
L5210
L5220
L5230
L5250
L5270
L5280
L5300
L5310
L5320
L5330
L5340
L5400
L5410
L5420
L5430
L5450
L5460
ORTHOTIC AND PROSTHETIC PROCEDURES (L-CODES)
MAP
Upper extremity fracture orthosis, wrist, prefabricated
Upper extrem.fracture orthosis, forearm, hand with wrist hinge, custom fabricated
Upper extremity fracture orthosis, combination of humeral, radius/ulnar, wrist
Addition to upper extremity orthosis, sock, fracture or equal, each
Upper limb orthosis, not otherwise specified
Replace girdle for Milwaukee orthosis
Replace trilateral socket brim
Replace quadrilateral socket brim, molded to patient model
Replace quadrilateral socket brim, custom fitted
Replace molded thigh lacer
Replace nonmolded thigh lacer
Replace molded calf lacer
Replace nonmolded calf lacer
Replace high roll cuff
Replace proximal and distal upright for KAFO
Replace metal bands KAFO, proximal thigh
Replace metal bands KAFOFO, calf or distal thigh
Replace leather cuff KAFO, proximal thigh
Replace leather cuff KAFOFO, calf or distal thigh
Replace pretibial shell
Repair of orthotic device, repair or replace minor parts
Pneumatic ankle control splint (e.g., Aircast), prefabricated
Pneumatic walking splint (e.g., Aircast), prefabricated
Pneumatic full leg splint (e.g., Aircast), prefabricated
Pneumatic knee splint (e.g., Aircast), prefabricated
Partial foot, shoe insert with longitudinal arch, toe filler
Partial foot, molded socket, ankle height, with toe filler
Partial foot, molded socket, tibial tubercle height, with toe filler
Ankle, Symes, molded socket, SACH foot
Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot
Below knee, molded socket, shin, SACH foot
Below knee, plastic socket, joints and thigh lacer, SACH foot
Knee disarticulation (or through knee), molded socket, external knee joints, shin,
Knee disarticulation, (or through knee), molded socket, bent knee configuration,
Above knee, molded socket, single axis constant friction knee, shin, SACH foot
Above knee, short prosthesis, no knee joint ("stubbies"), with foot blocks,
Above knee, short prosthesis, no knee joint ("stubbies"), articulated ankle/foot
Above knee, for proximal femoral focal deficiency, constant friction knee shin,
Hip dis-articulation, Canadian type; molded socket, hip joint, SACH foot
Hip dis-articulation, tilt table type, molded socket, locking hip joint, SACH foot
Hemipelvectomy, Canadian type; molded socket, hip joint, single axis constant
Below knee, molded socket, SACH foot, endoskeletal system, incld soft cover
Knee dis-articulation (or through knee), molded socket SACH foot endoskeletal
Above knee, molded socket, open end, SACH foot, endoskeletal system, single
Hip dis-articulation, Canadian type; molded socket, endoskeletal system, hip
Hemipelvectomy, Canadian type; molded socket, endoskeletal system, hip joint,
Immediate post-surgical or early fitting, application of initial rigid dressing,
Immediate post-surgical or early fitting, application of initial rigid dressing,
Immediate post-surgical or early fitting, application of initial rigid dressing, cast
Immediate post-surgical or early fitting, application of initial rigid dressing, each
Immediate post-surgical or early fitting, application of non-weight bearing rigid
Immediate post-surgical or early fitting, application of non-weight bearing rigid
$219.47
$496.93
$476.56
$20.85
BR
$1,107.83
$942.50
$748.37
$438.67
$354.66
$285.01
$358.70
$232.27
$276.12
$244.52
$87.00
$78.46
$90.62
$73.68
$431.00
BR
$58.25
$180.43
$123.02
$69.99
$400.00
$1,217.00
$2,226.00
$2,231.00
$2,691.00
$2,499.00
$3,215.69
$3,599.00
$3,869.00
$3,081.00
$2,332.00
$2,592.00
$4,198.00
$4,802.00
$4,760.75
$4,713.13
$2,612.75
$3,859.00
$3,815.00
$5,450.14
$5,823.31
$1,261.00
$333.00
$1,547.71
$420.12
$363.27
$476.46
L-Code-8
L-Code, Orthotic and Prosthetics Fee Table
L-Code procedures not listed on this table are BR
L5500
L5505
L5510
L5520
L5530
L5535
L5540
L5560
L5570
L5580
L5585
L5590
L5595
L5600
L5610
L5611
L5613
L5614
L5616
L5618
L5620
L5622
L5624
L5626
L5628
L5629
L5630
L5631
L5632
L5634
L5636
L5637
L5638
L5639
L5640
L5642
L5643
ORTHOTIC AND PROSTHETIC PROCEDURES (L-CODES)
MAP
Initial below knee "PTB" type socket, "USMC" or equal pylon, no cover SACH
Initial, above knee-knee dis-articulation, ischial level socket, SACH foot direct
Preparatory, below knee "PTB" type socket, SACH foot, plaster socket, molded
Preparatory, below knee "PTB" type socket, SACH foot, thermoplastic or equal,
direct formed
Preparatory, below knee "PTB" type socket, no cover, SACH foot, thermoplastic
or equal, molded
Preparatory, below knee "PTB" type socket, no cover, SACH foot, prefabricated
adjustable
Preparatory, below knee "PTB" type socket, no cover, SACH foot, laminated
socket, molded to
Preparatory, above knee-knee disarticulation, ischial level socket, SACH foot,
plaster socket
Preparatory, above knee-knee disarticulation, ischial level socket, thermoplastic,
direct form
Preparatory, above knee-knee disarticulation, ischial level socket, thermoplastic,
molded to
Preparatory, above knee-knee disarticulation, ischial level socket, prefabricated,
adjustable
Preparatory, above knee-knee disarticulation, ischial level socket, laminated
socket, molded
Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, SACH foot,
thermoplastic mold
Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, SACH foot,
laminated socket
Addition to lower extremity, endoskeletal above knee, hydracadence system
Addition to lower extremity, endoskeletal system above, 4ar linkage with friction
swing
Addition to lower extremity, endoskeletal above, 4ar linkage, with hydraulic swing
Addition to lower extremity, above knee--knee disarticulation, pneumatic swing
phase control
Addition to lower extremity, above knee, universal multiplex system, friction
swing phase
Addition to lower extremity, test socket, Symes
Addition to lower extremity, test socket, below knee
Addition to lower extremity, test socket, knee disarticulation
Addition to lower extremity, test socket, above knee
Addition to lower extremity, test socket, hip disarticulation
Addition to lower extremity, test socket, hemipelvectomy
Addition to lower extremity, below knee, acrylic socket
Addition to lower extremity, Symes type, expandable wall socket
Addition to lower extremity, above knee or knee disarticulation, acrylic socket
Addition to lower extremity, Symes type, "PTB" brim design socket
Addition to lower extremity, Symes type, posterior opening (Canadian) socket
Addition to lower extremity, Symes type, medial opening socket
Addition to lower extremity, below knee, total contact
Addition to lower extremity, below knee, leather socket
Addition to lower extremity, below knee, wood socket
Addition to lower extremity, knee disarticulation, leather socket
Addition to lower extremity, above knee, leather socket
Addition to lower extremity, hip disarticulation, flexible inner socket, external
frame
$1,262.00
$1,685.00
$1,535.00
$1,347.00
L-Code-9
$1,752.00
$1,569.73
$1,765.00
$1,829.00
$1,840.00
$2,352.00
$2,696.00
$2,225.22
$3,727.16
$4,115.89
$1,916.47
$1,491.40
$2,268.50
$3,508.49
$1,257.18
$654.32
$533.41
$729.81
$635.07
$777.71
$775.86
$220.64
$415.43
$305.04
$205.52
$281.57
$235.86
$294.15
$450.48
$1,037.83
$591.89
$573.50
$1,440.73
L-Code, Orthotic and Prosthetics Fee Table
L-Code procedures not listed on this table are BR
L5644
L5645
L5646
L5647
L5648
L5649
L5650
L5651
L5652
L5653
L5654
L5655
L5656
L5658
L5660
L5661
L5662
L5663
L5664
L5665
L5666
L5667
L5668
L5669
L5670
L5672
L5674
L5675
L5676
L5677
L5678
L5680
L5682
L5684
L5686
L5688
L5690
L5692
L5694
L5695
ORTHOTIC AND PROSTHETIC PROCEDURES (L-CODES)
MAP
Addition to lower extremity, above knee, wood socket
Addition to lower extremity, below knee, flexible inner socket, external frame
Addition to lower extremity, below knee, air cushion socket
Addition to lower extremity, below knee, suction socket
Addition to lower extremity, above knee, air cushion socket
Addition to lower extremity, ischial containment/narrow M-L socket
Addition to lower extremity, total contact, above knee or knee disarticulation
socket
Addition to lower extremity, above knee, flexible inner socket, external frame
Addition to lower extremity, suction suspension, above knee or knee
disarticulation socket
Addition to lower extremity, knee disarticulation, expandable wall socket
Addition to lower extremity, socket insert, Symes (Kemblo, Pelite, Aliplast,
Plastazote or
Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast,
Plastozote
Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite,
Aliplast,
Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast,
Plastozote
Addition to lower extremity, socket inset, Symes, silicone gel or equal
Addition to lower extremity, socket insert, multidurometer, Symes
Addition to lower extremity, socket insert, below knee, silicone gel or equal
Addition to lower extremity, socket insert, knee disarticulation, silicone gel or
equal
Addition to lower extremity, socket insert, above knee, silicone gel or equal
Addition to lower extremity, socket insert, multidurometer, below knee
Addition to lower extremity, below knee, cuff suspension
Addition to lower extremity, below knee/above knee, socket insert, suction
suspension,
Addition to lower extremity, below knee, molded distal cushion
Addition to lower extremity, below knee/above knee, socket insert, suction
suspension
Addition to lower extremity, below knee, molded supracondylar suspension
("PTS" or similar)
Addition to lower extremity, below knee, removable medial brim suspension
Addition to lower extremity, below knee, latex sleeve suspension or equal, each
Addition to lower extremity, below knee, latex sleeve suspension or equal, heavy
duty each
Addition to lower extremity, below knee, knee joints, single axis, pair
Addition to lower extremity, below knee, knee joints, polycentric, pair
Addition to lower extremity, below knee, joint covers, pair
Addition to lower extremity, below knee, thigh lacer, nonmolded
Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded
Addition to lower extremity, below knee, fork strap
Addition to lower extremity, below knee, back check (extension control)
Addition to lower extremity, below knee, waist belt, webbing
Addition to lower extremity, below knee, waist belt, padded and lined
Addition to lower extremity, above knee, pelvic control belt, light
Addition to lower extremity, above knee, pelvic control belt, padded and lined
Addition to lower extremity, above knee, pelvic control, sleeve suspension,
neoprene or equal
$546.73
$748.26
$507.18
$736.32
$609.43
$1,882.67
$451.88
L-Code-10
$1,111.63
$606.28
$661.74
$426.49
$348.15
$343.38
$336.56
$533.65
$563.29
$489.35
$637.86
$614.54
$473.96
$64.80
$1,390.99
$93.48
$1,060.00
$300.76
$276.02
$48.81
$66.16
$335.44
$456.40
$30.33
$281.74
$578.90
$44.54
$47.29
$56.53
$90.58
$123.00
$167.93
$150.96
L-Code, Orthotic and Prosthetics Fee Table
L-Code procedures not listed on this table are BR
L5696
L5697
L5698
L5699
L5700
L5701
L5702
L5704
L5705
L5706
L5707
L5710
L5711
L5712
L5714
L5716
L5718
L5722
L5724
L5726
L5728
L5780
L5785
L5790
L5795
L5810
L5811
L5812
L5816
L5818
L5822
L5824
L5828
L5830
ORTHOTIC AND PROSTHETIC PROCEDURES (L-CODES)
MAP
Addition to lower extremity, above knee or knee disarticulation, pelvic joint
Addition to lower extremity, above knee or knee disarticulation, pelvic band
Addition to lower extremity, above knee or knee disarticulation, Silesian bandage
All lower extremity prostheses, shoulder harness
Replacement, socket, below knee, molded to patient model
Replacement, socket, above knee/knee disarticulation including attachment
plate, molded
Replacement, socket, hip disarticulation, including hip joint, molded to patient
model
Replacement, custom shaped protective cover, below knee
Replacement, custom shaped protective cover, above knee
Replacement, custom shaped protective cover, knee disarticulation
Replacement, custom shaped protective cover, hip disarticulation
Addition, exoskeletal knee-shin system, single axis, manual lock
Addition, exoskeletal knee-shin system, single axis, manual lock, ultra-light
material
Addition, exoskeletal knee-shin system, single axis, friction swing and stance
phase control
Addition, exoskeletal knee-shin system, single axis, variable friction swing phase
control
Addition, exoskeletal knee-shin system, polycentric mechanical stance phase
lock
Addition, exoskeletal knee-shin system, polycentric, friction swing and stance
phase control
Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction
stance phase
Addition, exoskeletal knee-shin system, single axis, fluid swing phase control
Addition, exoskeletal knee-shin system, single axis, external joints fluid swing
Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase
control
Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic
swing phase
Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon
fiber or
Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon
fiber or
Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium,
carbon
Addition, endoskeletal knee-shin system, single axis, manual lock
Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light
material
Addition, endoskeletal knee-shin system, single axis friction swing and stance
phase control
Addition, endoskeletal knee-shin system, polycentric mechanical stance phase
lock
Addition, endoskeletal knee-shin system, polycentric, friction swing, and stance
phase control
Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction
stance phase
Addition, endoskeletal knee-shin system, single axis, fluid swing phase control
Addition, endoskeletal knee-shin system, single axis, fluid swing and stance
phase control
Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase
$171.28
$74.32
$96.56
$142.40
$2,534.95
$3,147.36
L-Code-11
$4,021.66
$436.72
$800.64
$780.94
$1,049.19
$332.93
$483.34
$398.87
$387.18
$674.65
$843.24
$835.75
$1,397.20
BR
$1,851.35
$1,059.79
$480.92
$665.57
$993.86
$450.67
$675.10
$495.00
$710.00
$888.94
$1,576.30
$1,400.00
$2,263.39
$1,756.46
L-Code, Orthotic and Prosthetics Fee Table
L-Code procedures not listed on this table are BR
ORTHOTIC AND PROSTHETIC PROCEDURES (L-CODES)
L5840
L5850
L5855
L5910
L5920
L5925
L5940
L5950
L5960
L5962
L5964
L5966
L5970
L5972
L5974
L5976
L5978
L5979
L5980
L5981
L5982
L5984
L5986
L5999
L6000
L6010
L6020
L6050
L6055
L6100
L6110
L6120
L6130
L6200
L6205
L6250
L6300
control
Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase
control
Addition, endoskeletal system, above knee or hip disarticulation, knee extension
assist
Addition, endoskeletal system, hip disarticulation, mechanical hip extension
assist
Addition, endoskeletal system, below knee, alignable system
Addition, endoskeletal system, above knee or hip disarticulation, alignable
system
Addition, endoskeletal system, above knee, knee disarticulation or hip
disarticulation, manual
Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon
Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon
fiber or
Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium,
Addition, endoskeletal system, below knee, flexible protective outer surface
covering system
Addition, endoskeletal system, above knee, flexible protective outer surface
covering system
Addition endoskeletal system, hip disarticulation, flexible protective outer surface
covering
All lower extremity prostheses, foot, external keel, SACH foot
All lower extremity prostheses, flexible keel foot (Safe, Sten, Bock Dynamic or
equal)
All lower extremity prostheses, foot, single axis ankle/foot
All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or
equal)
All lower extremity prostheses, foot, multixial ankle/foot
All lower extremity prostheses, multixial ankle/foot, dynamic response
All lower extremity prostheses, flex-foot system
All lower extremity prostheses, flex-walk system or equal
All exoskeletal lower extremity prostheses, axial rotation unit
All endoskeletal lower extremity prostheses, axial rotation unit
All lower extremity prostheses, multixial rotation unit ("MCP" or equal)
Lower extremity prosthesis, not otherwise classified
Partial hand, Robinids, thumb remaining (or equal)
Partial hand, Robinids, little and/or ring finger remaining (or equal)
Partial hand, Robon Aids, no finger remaining (or equal)
Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad
Wrist disarticulation, molded socket with expandable interface, flexible elbow
hinges, triceps
Below elbow, molded socket, flexible elbow hinge, triceps pad
Below elbow, molded socket (Muenster or Northwestern suspension types)
Below elbow, molded double wall split socket, step-up hinges, half cuff
Below elbow, molded double wall split socket, stump activated locking hinge, half
cuff
Elbow disarticulation, molded socket, outside locking hinge, forearm
Elbow disarticulation, molded socket with expandable interface, outside locking
hinges,
Above elbow, molded double wall socket, internal locking elbow, forearm
Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section,
L-Code-12
MAP
$1,980.00
$118.42
$285.88
$335.26
$491.14
$280.00
$464.30
BR
$892.37
$490.00
$798.56
$1,035.31
$187.99
$326.23
$215.70
$451.39
$270.13
$2,090.00
$2,917.79
$2,382.65
$535.13
$527.33
$586.57
BR
$1,229.90
$1,368.70
$1,276.09
$2,263.00
$2,450.75
$2,229.00
$2,284.04
$2,202.07
$2,396.27
$2,982.00
$3,370.85
$3,267.79
$3,448.64
L-Code, Orthotic and Prosthetics Fee Table
L-Code procedures not listed on this table are BR
ORTHOTIC AND PROSTHETIC PROCEDURES (L-CODES)
L6310
L6320
L6350
L6360
L6370
L6380
L6382
L6384
L6386
L6388
L6400
L6450
L6500
L6550
L6570
L6580
L6582
L6584
L6586
L6588
L6590
L6600
L6605
L6610
L6615
L6616
L6620
L6623
L6625
L6628
L6629
L6630
L6632
L6635
L6637
L6640
L6641
L6642
internal locking
Shoulder disarticulation, passive restoration (complete prosthesis)
Shoulder disarticulation, passive restoration (shoulder cap only)
Interscapular thoracic, molded socket, shoulder bulkhead, humeral section,
internal locking
Interscapular thoracic, passive restoration (complete prosthesis)
Interscapular thoracic, passive restoration (shoulder cap only)
Immediate post-surgical or early fitting, application of initial rigid dressing, and
one cast
Immediate post-surgical or early fitting, application of initial rigid dressing, and
one cast
Immediate post-surgical or early fitting, application of initial rigid dressing,
Immediate post-surgical or early fitting, each additional cast change and
realignment
Immediate post-surgical or early fitting, application of rigid dressing only
Below elbow, molded socket, endoskeletal system, including soft prosthetic
tissue shaping
Elbow disarticulation, molded socket, endoskeletal system, including soft
prosthetic tissue
Above elbow, molded socket, endoskeletal system, including soft prosthetic
tissue shaping
Shoulder disarticulation, molded socket, endoskeletal system, including soft
prosthetic tissue
Interscapular thoracic, molded socket, endoskeletal system, including soft
prosthetic tissue
Preparatory, wrist disarticulation or below elbow, single wall plastic socket,
molded to
Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist,
direct
Preparatory, elbow disarticulation or above elbow, single wall plastic socket,
Preparatory, elbow disarticulation or above elbow, single wall socket, friction
wrist,
Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic
Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket,
Upper extremity additions, polycentric hinge, pair
Upper extremity additions, single pivot hinge, pair
Upper extremity additions, flexible metal hinge, pair
Upper extremity addition, disconnect locking wrist unit
Upper extremity addition, additional disconnect insert for locking wrist unit, each
Upper extremity addition, flexion-friction wrist unit
Upper extremity addition, spring assisted rotational wrist unit with latch release
Upper extremity addition, rotation wrist unit with cable lock
Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal
Upper extremity addition, quick disconnect lamination collar with coupling piece,
Otto Bock or
Upper extremity addition, stainless steel, any wrist
Upper extremity addition, latex suspension sleeve, each
Upper extremity addition, lift assist for elbow
Upper extremity addition, nudge control elbow lock
Upper extremity addition, shoulder abduction joint, pair
Upper extremity addition, excursion amplifier pulley type
Upper extremity addition, excursion amplifier level type
L-Code-13
MAP
$2,809.00
$1,581.89
$3,625.73
$2,948.39
$1,880.09
$1,130.00
$1,520.00
$1,764.86
$371.72
$406.94
$2,147.89
$2,853.88
$2,856.22
$3,529.76
$4,051.49
$1,446.95
$1,273.99
$1,894.64
$1,734.41
$2,616.40
$2,435.32
$173.63
$171.44
$154.12
$160.80
$60.04
$280.66
$593.77
$492.31
$443.44
$135.43
$529.70
$60.14
$185.00
$339.89
$259.30
$148.50
$201.28
L-Code, Orthotic and Prosthetics Fee Table
L-Code procedures not listed on this table are BR
L6645
L6650
L6655
L6660
L6665
L6670
L6672
L6675
L6676
L6680
L6682
L6684
L6686
L6687
L6688
L6689
L6690
L6691
L6692
L6700
L6705
L6710
L6715
L6720
L6725
L6730
L6735
L6740
L6745
L6750
L6755
L6765
L6770
L6775
L6780
L6790
L6795
L6800
L6805
L6806
L6809
L6810
L6825
L6830
L6835
L6840
L6845
L6850
L6855
L6860
L6865
ORTHOTIC AND PROSTHETIC PROCEDURES (L-CODES)
MAP
Upper extremity addition, shoulder flexion abduction joint, each
Upper extremity addition, shoulder universal joint, each
Upper extremity addition, standard control cable, extra
Upper extremity addition, heavy duty control cable
Upper extremity addition, Teflon, or equal cable lining
Upper extremity addition, hook to hand, cable adapter
Upper extremity addition, harness, chest or shoulder, saddle type
Upper extremity addition, harness, figure of eight type, for single control
Upper extremity addition, harness, figure of eight type, for dual control
Upper extremity addition, test socket, wrist disarticulation or below elbow
Upper extremity addition, test socket, elbow disarticulation or above elbow
Upper extremity addition, test socket, shoulder disarticulation or interscapular
thoracic
Upper extremity addition, suction socket
Upper extremity addition, frame type socket, below elbow or wrist disarticulation
Upper extremity addition, frame type socket, above elbow or elbow disarticulation
Upper extremity addition, frame type socket, shoulder disarticulation
Upper extremity addition, frame type socket, interscapular-thoracic
Upper extremity addition, removable insert, each
Upper extremity addition, silicone gel insert or equal, each
Terminal device, hook Dorrance, or equal, model #3
Terminal device, hook Dorrance, or equal, model #5
Terminal device, hook, Dorrance, or equal, model #5X
Terminal device, hook, Dorrance, or equal, model #5XA
Terminal device, hook, Dorrance, or equal, model #6
Terminal device, hook, Dorrance, or equal, model #7
Terminal device, hook, Dorrance, or equal, model #7LO
Terminal device, hook, Dorrance, or equal, model #8
Terminal device, hook, Dorrance, or equal, model #8X
Terminal device, hook, Dorrance, or equal, model #88X
Terminal device, hook, Dorrance, or equal, model #10P
Terminal device, hook, Dorrance, or equal, model #10X
Terminal device, hook, Dorrance, or equal, model #12P
Terminal device, hook, Dorrance, or equal, model #99X
Terminal device, hook, Dorrance, or equal, model #555
Terminal device, hook, Dorrance, or equal, model #SS555
Terminal device, hook, Accu hook or equal
Terminal device, hook, 2 load or equal
Terminal device, hook, APRL VC or equal
Terminal device, modifier wrist flexion unit
Terminal device, hook, TRS Grip, VC
Terminal device, hook, TRS Super Sport, passive
Terminal device, pincher tool, Otto Bock or equal
Terminal device, hand, Dorrance, VO
Terminal device, hand, APRL, VC
Terminal device, hand, Sierra, VO
Terminal device, hand, Becker Imperial
Terminal device, hand, Becker Lock Grip
Terminal device, hand, Becker Pylite
Terminal device, hand, Robinids, VO
Terminal device, hand, Robinids, VO soft
Terminal device, hand, passive hand
$295.49
$313.32
$69.53
$84.96
$42.64
$44.39
$156.07
$111.16
$112.26
$396.63
$492.52
$575.62
L-Code-14
$546.47
$485.00
$490.36
$623.71
$636.49
$375.00
$517.66
$480.17
$281.90
$456.45
$435.00
$789.68
$465.24
$591.50
$275.82
$359.60
$329.03
$325.22
$324.30
$338.82
$326.63
$387.01
$413.69
$418.27
$1,145.60
$937.88
$314.94
$1,219.79
$343.46
$172.66
$955.02
$1,253.51
$1,091.93
$758.59
$704.22
$637.78
$811.19
$615.22
$301.42
L-Code, Orthotic and Prosthetics Fee Table
L-Code procedures not listed on this table are BR
L6875
L6880
L6890
L6895
L6900
L6905
L6910
L6915
L6920
L6925
L6930
L6935
L6940
L6945
L6950
L6955
L6960
L6965
L6970
L6975
L7010
L7015
L7020
L7025
L7030
L7035
L7040
L7170
L7180
L7260
L7261
L7266
L7272
L7274
L7360
ORTHOTIC AND PROSTHETIC PROCEDURES (L-CODES)
MAP
Terminal device, hand, Bock VC
Terminal device, hand, Bock VO
Terminal device, glove for above hands, production glove
Terminal device, glove for above hands, custom glove
Hand restoration (casts, shading and measurements included), partial hand, with
glove, thumb
Hand restoration (casts, shading and measurements included), partial hand, with
glove,
Hand restoration (casts, shading and measurements included), partial hand, with
glove,
Hand restoration (shading and measurements included), replacement glove for
above
Wrist disarticulation, external power, self-suspended inner socket, removable
forearm
Wrist disarticulation, external power, self-suspended inner socket, removable
forearm,
Below elbow, external power, self-suspended inner socket, removable forearm
shell,
Below elbow, external power, self-suspended inner socket, removable forearm
shell,
Elbow disarticulation, external power, molded inner socket, removable humeral
shell,
Elbow disarticulation, external power, molded inner socket, removable humeral
shell,
Above elbow, external power, molded inner socket, removable humeral shell,
internal
Above elbow, external power, molded inner socket, removable humeral shell,
internal
Shoulder disarticulation, external power, molded inner socket, removable
shoulder
Shoulder disarticulation, external power, molded inner socket, removable
shoulder shell,
Interscapular-thoracic, external power, molded inner socket, removable shoulder
shell,
Interscapular-thoracic, external power, molded inner socket, removable shoulder
shell,
Electronic hand, Otto Bock, Steeper or equal, switch controlled
Electronic hand, System Teknik, Variety Village or equal, switch controlled
Electronic greifer, Otto Bock or equal, switch controlled
Electronic hand, Otto Bock or equal, myoelectronically controlled
Electronic hand, System Teknik, Variety Village or equal, myoelectronically
controlled
Electronic greifer, Otto Bock or equal, myoelectronically controlled
Prehensile actuator, Hosmer or equal, switch controlled
Electronic elbow, BOSTON or equal, switch controlled
Electronic elbow, BOSTON, Utah or equal, myoelectronically controlled
Electronic wrist rotator, Otto Bock or equal
Electronic wrist rotator, for Utah arm
Servo control, Steeper or equal
Analogue control, UNB or equal
Proportional control, 12 volt, Utah or equal
Six volt battery, Otto Bock or equal, each
$719.47
$466.76
$190.00
$732.76
$1,989.50
L-Code-15
$1,990.23
$2,001.88
$774.57
$6,434.34
$6,874.02
$6,197.18
$6,841.72
$8,002.61
$8,927.91
$7,987.74
$9,263.27
$9,744.62
$11,544.00
$12,356.57
$13,619.84
$3,174.94
$5,611.94
$3,466.69
$3,428.95
$5,488.37
$3,648.62
$2,609.59
$5,427.59
$29,891.81
$1,821.71
$3,610.95
$916.48
$1,812.94
$5,621.72
$240.00
L-Code, Orthotic and Prosthetics Fee Table
L-Code procedures not listed on this table are BR
L7362
L7364
L7366
L7499
L7500
L7510
L8100
L8110
L8120
L8130
L8140
L8150
L8160
L8170
L8180
L8190
L8200
L8210
L8220
L8300
L8310
L8320
L8330
L8400
L8410
L8415
L8420
L8430
L8435
L8440
L8460
L8465
L8470
L8480
L8485
L8490
L8499
L8500
L8501
L8610
L8699
ORTHOTIC AND PROSTHETIC PROCEDURES (L-CODES)
MAP
Battery charger, six volt, Otto Bock or equal
Twelve volt battery, Utah or equal, each
Battery charger, 12 volt, Utah or equal
Unlisted procedures for upper extremity prosthesis
Repair of prosthetic device, hourly rate
Repair prosthetic device, repair or replace minor parts
Gradient compression stocking, below knee, medium weight, each
Gradient compression stocking, below knee, heavy weight, each
Gradient compression stocking, (Linton or equal), each thigh length
Gradient compression stocking, thigh length
Gradient compression stocking, thigh length
Gradient compression stocking, thigh length
Gradient compression stocking, full-length, each
Gradient compression stocking, full-length, chap style each
Gradient compression stocking,
Gradient compression stocking, waist length each
Gradient compression stocking, waist length, each
Gradient compression stocking, custom-made
Gradient compression, elastic stocking, lymphedema
Truss, single with standard pad
Truss, double with standard pads
Truss, addition to standard pad, water pad
Truss, addition to standard pad, scrotal pad
Prosthetic sheath, below knee, each
Prosthetic sheath, above knee, each
Prosthetic sheath, upper limb, each
Prosthetic sock, multiple ply, below knee, each
Prosthetic sock, multiple ply, above knee, each
Prosthetic sock, multiple ply, upper limb, each
Prosthetic shrinker, below knee, each
Prosthetic shrinker, above knee, each
Prosthetic shrinker, upper limb, each
Stump sock, single ply, fitting, below knee, each
Stump sock, single ply, fitting, above knee, each
Stump sock, single ply, fitting, upper limb, each
Addition to prosthetic sheath/sock, air seal suction retention system
Unlisted procedure for miscellaneous prosthetic services
Artificial larynx, any type
Tracheostomy speaking valve
Ocular
Prosthetic implant, not otherwise specified
$242.00
$392.77
$540.20
BR
$80.00
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$58.56
$92.46
$37.11
$34.27
$23.02
$19.18
$19.84
$18.01
$20.50
$19.46
$38.71
$61.69
$45.16
$6.18
$8.52
$10.17
$134.87
BR
BR
BR
BR
BR
L-Code-16
Chapter 15
Hospital and Facility Services
This section stipulates policies and procedures that are unique to hospitals and other
facilities. Additional policies and procedures that apply to all providers are listed in
Chapters 1-5 of this manual.
General Information and Overview
Facilities that are licensed by the state of Michigan will be paid in accord with the Health
Care Services Rules for services provided to injured workers. A carrier is not required
to pay for facility services when a facility is not licensed. A facility may not balance-bill
an injured worker for compensable services rendered to treat a work related illness or
injury.
When a hospital located outside the state of Michigan bills a carrier for services
rendered to a Michigan injured worker, the carrier should use the out-of-state ratio to
process the charges. If the out-of-state hospital does not accept the Michigan fee
schedule, the carrier must resolve the issue with the provider to prevent the Michigan
injured worker from being balance-billed.
Licensed Facility Services (including hospitals)
A facility, as defined by the Health Care Services Rules, shall submit facility charges on
a UB-92 claim form to the carrier. The "Michigan Uniform Billing Manual" contains
instructions for facility billing and can be ordered from the Michigan Health and Hospital
Association, 6215 West St. Joseph Hwy, Lansing MI, 48917, (517) 323-3443.
A hospital or a facility shall include the following information on the UB-92 claim form:

Revenue codes

ICD.9.CM code

CPTTM codes identifying the surgical, radiological, laboratory, medicine, and E/M
services
A hospital billing for outpatient laboratory or physical medicine services, (e.g., physical
and occupational therapy and speech therapy) will identify the services performed with
revenue codes. CPTTM procedural coding is not required for PT, OT, and speech
therapy performed in the hospital setting as the services are reimbursed by the ratio
methodology. Refer to Part 9, Section B, on pp. 36-38 of the Health Care Rules for
facility billing. Reimbursement for facility services is found in Part 10, Section B, on pp.
42-44 of the Rules.
15-1
Chapter 15 Hospital and Facility Services
A facility billing for a practitioner service shall submit the charges on the HCFA 1500
claim form.
Examples of Facility Billing for Practitioner Services:

A hospital billing for a CRNA or anesthesiologist, or both

A hospital billing for a radiologist

Professional component of a laboratory or medicine service

A hospital or hospital system-owned occupational or industrial clinic

A hospital or hospital system-owned office practice
Facility other than a Hospital
A licensed facility other than a hospital must also use the UB-92 claim form to submit
charges and must follow the billing procedures outlined in the UB-92 Billing Manual. A
licensed facility other than a hospital will be reimbursed not more than the provider’s
usual and customary charge or reasonable amount, whichever is less.
When a licensed facility other than a hospital bills radiology or laboratory services, only
the technical services shall be billed on the UB-92 claim form. Any professional
charges, including anesthesiology services, shall be billed on the HCFA 1500 claim
form.
Note: To verify facility licensure, the carrier may contact the Bureau of Health Systems
at (517) 241-2626. A booklet listing all of the licensed facilities and the addresses can
be purchased from the Bureau of Health Systems, PO Box 30664, Lansing MI, 48909.
Reimbursement for Hospital Facility Services
Hospital Ratio Payment Methodology
The following hospital services are paid by the ratio methodology:





Inpatient or observation care
Emergency department care
Physical medicine services (occupational, physical, and speech therapy)
Outpatient surgery services
Laboratory services and outpatient services not listed in Table 10924 of the
Health Care Services Rules, R 418.1010924.
Note: The following "technical" services performed in the hospital would not
have professional components and must also be paid by the ratio methodology:
Rev 2002
15-2
1. Casting and strapping procedures performed by hospital technicians
2. EKG, tracing only procedures
Note: Procedure codes describing professional service only shall not be
included on the UB-92. Examples: 53670, 93000, 93015, 93040, and 93720.
Calculating Hospital Payments by Ratio Methodology
The carrier will use the following formulas to calculate hospital reimbursement for ratio
methodology payments:

Paying a properly submitted bill within 30 days:
(Appropriate charges x hospital ratio for the date of service x 107%)

Paying a properly submitted bill after 30 days:
(Appropriate charges x hospital ratio for the date of service x 110%)
Billing for Facility Component of Minor Services Performed in the Outpatient
Hospital Setting
When procedures located in Table 10924 are performed in the outpatient hospital
setting after the initial 10 days of care for an injury, the hospital shall only be paid either
the technical component of the procedure listed in the rules or 60% of the MAP for the
medical and surgical procedure codes if no technical component is listed. When
radiology procedures are performed in the outpatient facility after the initial 10 days of
care, the hospital will be paid by the relative value for the technical component (-TC) of
the procedure.
The minor procedures listed in Table 10924 are those procedures that could safely be
performed in settings other than an outpatient hospital and concerns the technical
portion of the procedure only.
The following are exceptions to this rule and are paid by ratio methodology:
1. Services received in the first 10 days of commencing care for a work injury
2. Inpatient or observation stays or services appropriately performed in an
emergency room (ex: Urgent or emergency services performed after the first 10
days of care that are required after the treating practitioner’s routine office hours)
3. Outpatient surgery
4. When service is combined with another procedure not considered to be minor
(ex: a cat scan, a minor procedure in Table 10924, performed with a
myelogram or other outpatient surgery)
15-3
Chapter 15 Hospital and Facility Services
Note: The following table was excerpted from the Health Care Services Rules,
R 418.10924:
10060
10120
10140
10160
11000
11040
11100-11101
11720-11750
11900-11901
12001-12004
15860
16000
16020-16030
20500
20500
20550-20610
TABLE 10924-Facility Services
20665-20670
40800
67700
23065
40804
67715-67805
23330
40820
67810-67825
24065
41000-41005
67938
24200
41800-41805
69000
25065
42310
69020
26010
45300
70030-70360
27040
45330
70450-71030
27086
46050
71100-72220
27323
50398
73000-74020
27613
51000
74400-74420
28001
51700-51710
78300-78699
28190
53600-53661
90901-90911
30000-30100
53670-53675
92002-92014
30300
65205-65222
92230-92504
30901
92531-92599
92230-92499
93740
94010-95065
95115-95199
95180
95860-95904
95930-95937
98925-98943
99195
99201-99215
99241-99245
99281-99285
99801-99815
Table 10924 listed above for the facility component of the service corresponds to Table
10916 listed below. The corresponding Table 10916 was also excerpted from the
Health Care Services Rules and concerns the practitioner portion for the services on the
table.
Billing for Practitioner Component for Minor Services Performed in the Outpatient
Hospital
When a practitioner performs a procedure from Table 10916 in the outpatient
hospital setting, the practitioner must identify the service with modifier -26 to
signify the professional component and will be paid 40% of the MAP allowance.
Exceptions to the practitioner services in Table 10916 are as follows:

An emergency room physician providing emergency room services is paid at
100% of the MAP
Note: Hospital occupational clinics are required to bill all services on the HCFA
1500 as a practitioner service, using site of service "3". The hospital should not
"split-bill" with facility charges on the UB-92 and professional charges on the
HCFA 1500. The hospital occupational clinic shall be paid as a practitioner and
receive 100% of the MAP amounts listed in this manual.
Rev 2002
15-4
Chapter 15 Hospital and Facility Services
10060
10120
10140
10160
11000
11040
11100-11101
11720-11750
11900-11901
12001-12004
15860
16000
16020-16030
20500
20520
20550-20610
20665-20670
23065
23330
24065
24200
25065
26010
27040
27086
27323
27613
28001
28190
3000-30100
30200-30210
30300
TABLE 10916
30901
40800
40804
40820
41000-41005
41800-41805
42300
42310
45300
45330
46050
50398
51000
51700-51710
53600-53661
53670-53675
Rev 2002
15-5
65205-65222
67700
67715-67805
67810-67825
67938
69000
69020
70030-70360
70450-71030
71100-72220
73000-74420
74400-74420
78300-78699
90901-90911
92002-92014
92230-92504
92531-92599
93740
94010-95065
95115-95199
95180
95860-95904
95930-95937
98925-98943
99195
99201-99215
99241-99245
90801-99815
Fiscal
Year
Ending
Hospital Name
12/31/1998
06/30/1999
03/31/1999
09/30/1999
06/30/1999
06/30/1999
06/30/1999
12/31/1998
06/30/1999
08/31/1999
06/30/1999
12/31/1998
12/31/1998
12/31/1998
12/31/1998
12/31/1998
09/30/1999
03/31/1999
12/31/1998
12/31/1998
09/30/1999
12/31/1998
12/31/1998
09/30/1999
03/31/1999
06/30/1999
12/31/1998
06/30/1999
12/31/1998
12/31/1998
06/30/1999
06/30/1999
12/31/1998
12/31/1998
09/30/1999
06/30/1999
06/30/1999
12/31/1998
06/30/1999
12/31/1998
03/31/1999
12/31/1998
06/30/1999
Allegan General Hospital
Alpena General Hospital
Aurora Healthcare, Inc.
Baraga County Memorial Hospital
Battle Creek Health System
Bay Medical Center
Bell Memorial Hospital
Bi-County Community Hospital
Bixby Hospital
Bon Secours Hospital
Borgess Hospital
Botsford General Osteopathic Hospital
Bronson Methodist Hospital
Bronson Vicksburg Hospital
Caro Community Hospital
Carson City Osteopathic Hospital
Central Michigan Community Hospital
Charlevoix Area Hospital
Chelsea Community Hospital
Children's Hospital Of Michigan
Chippewa War Memorial Hospital
Clinton Memorial Hospital
Community Health Center
Community Hospital, Watervliet
Community Memorial Hospital
Covenant Medical Center, Inc.
Crittenton Hospital
Deckerville Community Hospital
Detroit Receiving Hospital
Dickinson County Healthcare System
Doctors Hospital Of Jackson
Eaton Rapids Medical Center
Edward W. Sparrow Hospital
Forest View Psychiatric Hospital
Garden City Osteopathic Hospital
Genesys Regional Med Center
Gerber Memorial Hospital
Grand View Hospital
Gratiot Community Hospital
Great Lakes Regional Rehab. Hospital
Hackley Hospital
Harbor Beach Community Hospital
Harbor Oaks Hospital
16-7
Maximum Payment Ratio
Total Operating Exp /
Total Patient Revenues
0.6544
0.6127
0.5643
0.7950
0.6168
0.5881
0.6604
0.5937
0.6931
0.4709
0.7535
0.5737
0.6884
0.7398
0.6626
0.5767
0.6303
0.6810
0.7270
0.6847
0.6181
0.8265
0.5770
0.6727
0.6327
0.4868
0.4404
0.7810
0.7938
0.5783
0.6044
0.7159
0.6064
0.4962
0.4126
0.6265
0.6557
0.7732
0.6130
0.4926
0.6399
0.7311
0.5748
Chapter 15 Hospital and Facility Services
Fiscal
Year
Ending
Hospital Name
Harper-Hutzel Hospital
Havenwyck Hospital
Hayes-Green-Beach Memorial Hospital
Healthsource Saginaw
Helen Newberry Joy Hospital
Henry Ford Hospital
Henry Ford Wyandotte Hospital
Herrick Memorial Hospital, Inc.
Hills & Dales General Hospital
Hillsdale Community Health Center
Holland Community Hospital
Hurley Medical Center
Huron Memorial Hospital
Huron Valley-Sinai Hospital
Ingham Regional Medical Center
Intensiva Hospital Of Macomb County, Inc
Ionia County Memorial Hospital
Iron County Community Hospitals, Inc.
Kalkaska Memorial Health Center
Kelsey Memorial Hospital
Kern Hospital & Medical Center
Keweenaw Memorial Medical Center
Kingswood Psychiatric Hospital
Lake View Community Hospital
Lakeland Medical Center, St. Joseph
Lakeshore Community Hospital
Lapeer Regional Hospital
Lee Memorial Hospital
Leelanau Memorial Hospital
Mackinac Straits Hospital
Madison Community Hospital
Marlette Community Hospital
Marquette General Hospital
Mary Free Bed Hospital
Mckenzie Memorial Hospital
Mclaren General Hospital
Mcpherson Hospital
Mecosta County General Hospital
Memorial Healthcare Center, Owosso
Memorial Medical Center Of West Michigan
Mercy General Health Partners, Muskegon
Mercy Hospital - Port Huron
Mercy Hospital, Cadillac
Hsp Ratio-2
12/31/1998
06/30/1999
03/31/1999
12/31/1998
12/31/1998
12/31/1998
12/31/1998
06/30/1999
03/31/1999
06/30/1999
03/31/1999
06/30/1999
09/30/1999
12/31/1998
09/30/1999
12/31/1998
06/30/1999
12/31/1998
06/30/1999
12/31/1998
12/31/1998
09/30/1999
12/31/1998
03/31/1999
09/30/1999
12/31/1998
09/30/1999
06/30/1999
06/30/1999
03/31/1999
12/31/1998
06/30/1999
06/30/1999
03/31/1999
09/30/1999
09/30/1999
06/30/1999
06/30/1999
12/31/1998
09/30/1999
06/30/1999
06/30/1999
06/30/1999
Maximum Payment Ratio
Total Operating Exp /
Total Patient Revenues
0.6682
0.4845
0.8029
0.9733
0.7413
0.7253
0.4738
0.6620
0.7224
0.5463
0.7165
0.6612
0.6375
0.4890
0.5834
0.4251
0.5753
0.6901
0.8082
0.7313
0.5730
0.7185
0.7584
0.6632
0.6706
0.7233
0.4604
0.6674
1.0336
0.9226
0.9199
0.6766
0.6168
0.7704
0.8640
0.5006
0.5502
0.6259
0.5600
0.5776
0.5849
0.5823
0.5870
Chapter 15 Hospital and Facility Services
Fiscal
Year
Ending
Hospital Name
Mercy Hospital, Grayling
Mercy-Memorial Hospital
Metropolitan Hospital, Grand Rapids
Mid Michigan Regional Med Center - Midland
Mid Michigan Reg. Med. Center - Clare
Mid Michigan Reg. Med. Center - Gladwin
Mt. Clemens General Osteopathic Hospital
Munising Memorial Hospital
Munson Medical Center
North Oakland Medical Centers
North Ottawa Community Hospital
Northern Michigan Hospitals, Inc.
Oaklawn Hospital
Oakwood Hospital And Medical Center
Ontonagon Memorial Hospital
Otsego County Memorial Hospital
Paul Oliver Memorial Hospital
Pennock Hospital
Pine Rest Christian Hospital
Pontiac Osteopathic Hospital
Port Huron Hospital
Portage Hospital
Providence Hospital
Rehabilitation Institute
Renaissance Hospital & Medical Centers
Riverside Osteopathic Hospital
Rogers City Rehabilitation Hospital
Saline Community Hospital
Scheurer Hospital
Schoolcraft Memorial Hospital
Select Specialty Hospital-Flint
Select Specialty Hospital-Western Michigan
Sheridan Community Hospital
Sinai-Grace Hospital
South Haven Community Hospital
Southwestern Michigan Rehabilitation
Spectrum Health – Downtown Campus
Spectrum Health - East Campus
Spectrum Health - Kent Community Campus
Spectrum Health - Reed City Campus
St. Francis Hospital
St. John Health System Detroit-Macomb Cam.
St. John Hospital & Medical Center
Hsp Ratio-3
06/30/1999
06/30/1999
09/30/1999
06/30/1999
06/30/1999
06/30/1999
12/31/1998
03/31/1999
06/30/1999
12/31/1998
06/30/1999
12/31/1998
12/31/1998
12/31/1998
03/31/1999
12/31/1998
08/31/1999
09/30/1999
06/30/1999
06/30/1999
06/30/1999
06/30/1999
06/30/1999
12/31/1998
12/31/1998
12/31/1998
07/31/1999
06/30/1999
06/30/1999
12/31/1998
01/31/1999
06/30/1999
03/31/1999
12/31/1998
06/30/1999
06/30/1999
06/30/1999
06/30/1999
12/31/1998
06/30/1999
09/30/1999
06/30/1999
06/30/1999
Maximum Payment Ratio
Total Operating Exp /
Total Patient Revenues
0.7158
0.5578
0.7522
0.6760
0.5796
0.6355
0.5269
0.7287
0.6612
0.4777
0.6514
0.6191
0.6158
0.5824
0.7557
0.7426
0.8457
0.6355
0.4171
0.6387
0.5428
0.6413
0.5463
0.8562
1.0915
0.5479
0.9272
0.5024
0.6529
0.7598
0.4665
0.4562
0.6608
0.7183
0.6134
0.7561
0.7458
0.7214
0.7906
0.6809
0.6167
0.5342
0.4972
Chapter 15 Hospital and Facility Services
Fiscal
Year
Ending
Hospital Name
St. John Northeast Community Hospital
St. John Oakland Hospital
St. John River District Hospital
St. Joseph Hospital – East
St. Joseph Mercy Hospital - Ann Arbor
St. Joseph Mercy Hospital Oakland Pontiac
St. Mary Mercy Hospital - Livonia
St. Mary's Medical Center - Saginaw
St. Mary's Mercy Medical Center – Gr. Rapids
Standish Community Hospital
Straith Memorial Hospital
Sturgis Memorial Hospital
Tawas St. Joseph Hospital
Three Rivers Hospital
Trillium Hospital
United Memorial Hospital
University Health System
Vencor Hospital -Lincoln Park
Vencor Hospital -Metro Detroit
W. A. Foote Memorial Hospital
West Branch Regional Medical Center
West Shore Community Hospital
William Beaumont Hospital
Zeeland Community Hospital
Weighted State Average-Out of State Hsp.
Hsp Ratio-4
06/30/1999
06/30/1999
06/30/1999
06/30/1999
06/30/1999
06/30/1999
06/30/1999
06/30/1999
06/30/1999
06/30/1999
10/31/1998
09/30/1999
06/30/1999
12/31/1998
12/31/1998
06/30/1999
06/30/1999
08/31/1999
08/31/1999
06/30/1999
03/31/1999
06/30/1999
12/31/1998
09/30/1999
Maximum Payment Ratio
Total Operating Exp /
Total Patient Revenues
0.5793
0.6318
0.5945
0.4612
0.5718
0.5856
0.5185
0.5881
0.6862
0.5863
0.4699
0.6881
0.7423
0.7595
0.7221
0.6500
0.7987
0.2715
0.3711
0.6786
0.5921
0.6963
0.4388
0.6812
0.6032
Chapter 16
Bureau and Miscellaneous Information
This section contains bureau contact information and examples of the forms used in
workers’ compensation. Also included in this chapter are samples of the provider claim
forms.
Bureau Contact Numbers
A provider may call (517) 322-1885 or (888) 396-5041, Ext. 2, to obtain carrier
information. When calling, be sure to have the following information:


The employer’s name and address
The date of injury
Bureau forms (including 104B forms) and information may be obtained by calling (888)
396-5041, Ext. 3. Requests for forms can either be e-mailed to
www.bwdcinfo@cis.state.mi.us or faxed to 517-322-1808. All requests should include a
contact name, phone number, company, street address, city, state, zip code, the
requested form name and/or number, and quantity. In addition, you may print forms
directly from our website: www.cis.state.mi.us/wkrcomp/forms.htm
Questions from an injured worker may be directed to (517) 241-8999 or (888) 3965041, Ext 1.
Fee schedule and billing questions may be directed to (517) 322-5896, (517) 3225433 or (888) 396-5041, Ext. 6.
To request a copy of the Health Care Services Rules or Fee Schedule call (517)
322-5433 or (888) 396-5041, Ext 6. The Health Care Services Rules, Fee Schedule,
and order form to obtain a copy of the rules (three-hole punched w/tabs) or CD-ROM
version are also located on the bureau website: http://www.cis.state.mi.us/wkrcomp/.
Providers with questions about completing the 104B form may call (517) 322-5430 or
(888) 396-5041, Ext. 6. Other questions may be directed to (517) 322-5991 or (888)
396-5041, Ext. 8.
Note: Hearings are generally scheduled within 6-8 weeks. Allow for this
processing time to elapse before contacting the bureau.
Carriers may direct questions regarding the completion of the forms, “Annual Medical
Payment Report” or “Certification of the Carriers’ Professional Review Program” to (517)
322-5430. or (888) 396-5041, Ext. 6.
16-7
Claim Forms


The standard practitioner claim form is the most recent HCFA 1500 form
(12-90).
The standard facility claim form is the UB-92 form.

The standard ADA claim form (dental claim form).

The universal pharmacy claim form.
Bureau Forms

"Sample Reconsideration” This is not a bureau requirement but is
optional for provider usage.

"Application for Mediation" (104B). Contact the bureau to obtain the
original orange-colored form.

"Carriers Explanation of Benefits"

"Annual Medical Payment"

"A Hospital’s Request for Adjustment to their Maximum Payment
Ratio"

"Application for Certification of a Carrier’s Professional Health Care
Review Program"

"Notice of Certification of a Carrier’s Professional Health Care
Review Program"
SOURCE DOCUMENTS
The following source documents as adopted by reference in the Health Care
Services Rules, R 418.10107, and were used in preparing this manual. You may
order these documents from the publisher:






Physicians Current Procedural Terminology (CPT TM)
Medicare’s National Level II Codes, HCPCS
RBRVS, Fee Schedule: The Physicians’ Guide
International Classification of Diseases
Red Book
Michigan Uniform Billing Manual
Rev 2002
16-7
Sample Reconsideration
WORKER'S COMPENSATION HEALTH CARE SERVICES
PROVIDER'S REQUEST FOR RECONSIDERATION
REQUEST DATE
COPY 1 CARRIER
COPY 2 PROVIDER
PROVIDER NAME
EMPLOYEE NAME
STREET ADDRESS
STREET ADDRESS
CITY
STATE
ZIP CODE
CITY
STATE
SOCIAL SECURITY/FEIN NUMBER*
SOCIAL SECURITY NUMBER*
PATIENT ACCOUNT NUMBER
DATE OF BILL
ZIP CODE
DATE OF INJURY
CARRIER NAME
TELEPHONE NUMBER
STREET ADDRESS
CITY
STATE
ZIP CODE
CLAIM NUMBER
EMPLOYER NAME
DATE(S) OF SERVICE
CHARGE
$
PAYMENT
$
REQUESTED AMOUNT
$
REASONS FOR RECONSIDERATION (Detailed Statement)
DOCUMENTS ATTACHED:
BWC-739
REQUESTED REPORT
OFFICE NOTES
BILL
CONTACT PERSON AND TELEPHONE NUMBER
*PROTECTED INFORMATION TO BE USED FOR IDENTIFICATION PURPOSES
16-3
APPLICATION FOR CERTIFICATION OF A CARRIERS=
PROFESSIONAL HEALTH CARE REVIEW PROGRAM
Michigan Department of Consumer & Industry Services
Bureau of Workers= Disability Compensation
Health Care Services Division
PO Box 30016, Lansing, Michigan 48909
Date of Application
Initial


Renewal
Note: A new application must be submitted whenever there is a change in carrier, service company, or review company.
This form is required in accordance with Part 12, R 418.101206 of the Worker=s Compensation Health Care Services Rules to receive
certification of a carrier’s professional review program.
I. CARRIER
Carrier
Service Company
Review Company
NAIC NO., Self-Insured No., or FEIN
Bureau Assigned A - Number
Employer Identification
Name
Name
Name
Address (Street)
Address (Street)
Address (Street)
City, State, Zip Code
City, State, Zip Code
City, State, Zip Code
Telephone No. (Include area code)
Telephone No. (Include area code)
Telephone No. (Include area code)
Contact Person
Contact Person
Contact Person
II. METHODOLOGY/REVIEW STAFF AND CREDENTIALS
Attach the methodology, according to bureau procedure, used to perform a carrier’s professional review.
R 418.101204(5)(a)-(c) requires that medical appropriateness of services shall be determined through one of the
following approaches:
1) Review by licensed, registered, or certified health care professionals.
2) The application by others of criteria developed by licensed, registered, or certified health care professionals.
3) A combination of (1) and (2) according to the type of covered injury or illness.
The methodology should include a list of all licensed, registered, or certified health care professionals reviewing case
records and medical bills for the above carrier. Provide current licensure information (license #, state of issue, date of
expiration and restrictions) and qualifications for medical bill review. In addition, include a list of all peer reviewers with
current license information and specialty.*When a service company submits applications for numerous self-insured
employers, and the methodology is identical, it is not necessary to submit the professional review methodology more
than once. The bureau will maintain on file, the review methodology for each service company.
**Methodology for professional certification must be submitted once every three years or whenever changes occur.
III. AUTHORIZED SIGNATURE
By signing this form, I certify that the information included on this form is correct and complete to the best of my knowledge and that the
professional review methodology is attached or has already been submitted by the service company and/or their designated agent. I
understand that submitting false information is cause for denial of the application or will subject me to penalties as provided by law.
Authorized Signature (In Ink)
Authorized Name (Typed)
16-3
Date
BWC-590 (REV. 01/01) (Formerly MDL-590)
16-4
ANNUAL MEDICAL PAYMENT REPORT
Michigan Department of Consumer & Industry Services
Bureau of Workers= Disability Compensation
Health Care Services Division
PO Box 30016, Lansing, Michigan 48909
Due by February 28th Year Ending 200_
I. CARRIER INFORMATION
Carrier Name
Carrier NAIC No., Self-Insured No., or FEIN No
Carrier Address (Street)
Carrier Telephone No. (Include area code)
Carrier City, State, ZIP Code
Carrier Contact Person
Service company or Review Company submitting the Information
Address
Contact Person
and(Street)
Telephone No. (Include area code)
II. ANNUAL MEDICAL PAYMENT REPORT
Include data for payment of all medical expenditures.
Do not include payments for the following:
a. Indemnity payments
b. Mileage reimbursement
c. Vocational rehabilitation or medical case management expenses
d. Independent medical examinations or legal expenses
Case Type
Number of Cases
Total Dollars Spent for Medical Care
Medical Only
$
Wage Loss
$
By signing this form, I certify that the information included in this annual medical payment report and accompanying attachments, if any, is true,
correct and complete to the best of my knowledge.
Authorized Signature (In ink)
Authorized Name (Typed)
Date
Authority:
Workers Compensation Health Care Services Rules, part 14, R 418.101401
Completion: Mandatory. Must completed and submitted to the bureau by 2.28 annually for the previous year.
Penalty:
Failure to provide data shall prevent certification of the Carrier's Professional Health Care Review Program pursuant to Part 12, R
418.101206
BWC-406 (REV. 04-00) (Formerly MDL-406)
16-5
A HOSPITAL’S REQUEST for ADJUSTMENT
To the MAXIMUM PAYMENT RATIO
Michigan Department of Consumer & Industry Services
Bureau of Workers= Disability Compensation
Health Care Services Division
PO Box 30016, Lansing, Michigan 48909
Application Date
Fiscal Year
This form is required in accordance with Part 11, R 418.101103 of the Worker=s Compensation Health Care Services Rules
for an adjustment to the worker=s compensation maximum payment ratio. Do not submit unless the documentation
supports an increased payment ratio and the criteria in the rules is met
I. HOSPITAL
Name
Employer Identification Number
Address (Street)
Telephone No. (Include are code)
City, State, ZIP Code
Contact Person
II. COST INFORMATION
This information is required pursuant to R 418.101103 for the calculation and revision of the maximum
payment ratio for hospital facilities. All information in the table below should reflect the hospital=s most
recent fiscal year reported on the G-2 worksheet.
4) Enter total operating expenses for the most recent fiscal year reported on
the "statement of patient revenues and operating expenses, G-2
worksheet."
$
5) Enter total patient revenues for most recent fiscal year as reported on the
"statement of patient revenues and operating expenses, G-2 worksheet."
$
3) Total charges for all worker’s compensation cases
$
By signing this form, I certify that the information included on this form and accompanying attachments, if any, is
true, correct, and complete to the best of my knowledge. I understand that submitting false information is cause for
denial of the underpayment adjustment or will subject me to penalties as provided by law.
Authorized Name (Typed)
Copy 1
Copy 2
Authorized Signature (In ink)
Health Care Services
Division
Hospital
BWC-581 (REV. 05-00) (Formerly MDL-581)
16-6
Telephone No
Date
Copy 1
Provider
Copy 2
Carrier
Copy 3
Employee
Carrier’s Explanation of Benefits
Date processed
State of Michigan Department of Consumer and Industry Services
Bureau of Workers’ Disability Compensation
Health Care Services Division
Page
DIRECT ALL PAYMENT INQUIRIES AND REQUESTS FOR RECONSIDERATION TO THE CARRIER
Carrier Name
Service Company
Street Address
City
NAICS/Self-Insured
MI
Zip Code
Employer Name
Telephone Number
Claim Number
Provider Name
Employee Name
Street Address
Street Address
City
State
Zip Code
City
State
Social Security/FEIN Number*
Social Security Number *
Patient Account Number
Date of Injury
Date of the
Zip Code
Date bill received by Carrier
Provider Bill
PROVIDER:
EMPLOYEE:
IF YOU INTEND TO SEEK RECONSIDERATION, PLEASE CONTACT
THE CARRIER INDICATED ABOVE WITHIN 30 CALENDAR DAYS OF
RECEIPT OF THIS NOTICE. IF ADDITIONAL INFORMATION IS
REQUESTED, PLEASE FORWARD THE INFORMATION TO THE
CARRIER.
FOR INFORMATION ONLY. THIS IS NOT A BILL. IF YOU ARE BILLED FOR
ANY SERVICES RELATED TO THIS WORKERS’ COMPENSATION CLAIM,
DO NOT PAY. DO CALL THE CARRIER LISTED ABOVE.
Date of Service
Place of Procedure Code
Service
and Modifier
Description--If Needed
Diagnosis
Days or
Code
Units
Charge
Payment
Note
THIS IS NOT A BILL
Provider/Employee: R 418.10105 and Rule 1013013(3) of the Worker's Compensation Health Care Services
Rules require that the carrier notify the employee and the provider that the rules prohibit a provider from billing
an employee for any amount for health care services provided for the treatment of a covered work-related injury
or illness when that 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. The carrier shall request the
employee to notify the carrier if the provider bills the employee.
Total Charge
This form is required as set forth in Part 10, R 418.101001 (4) and Part 13 R 418.101301 (1) and (4) of the Workers’ Compensation Health
Care Services Rules.
*PROTECTED INFORMATION TO BE USED FOR IDENTIFICATION PURPOSES
BWC-739 (Rev.02-01) (Formerly MDL-739)
16-7
Payment
Application for Mediation Form B
This form, commonly known as a 104B, is submitted on behalf of: Health Care
Providers, Insurance Companies, or Self-Insured Employers to resolve disputes
involving medical services.
This form must be filed on the original orange form obtained from the bureau.
You may order by fax at (517) 322-1808 or by phone (888) 396-5041, or e-mail
your request to www.bwdcinfo@cis.state.mi.us.
16-8
UB-92 Claim Form
16-9
1500 HCFA Claim Form
16-9
American Dentist’s Statement
16-9
Universal Pharmacy Claim Form
16-9