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).” Rev 2002 1-1 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. Rev 2002 1-2 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 1-3 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 1-4 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. 1-5 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: Rev 2002 2-1 Chapter 2 General Policy 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 Rev 2002 2-2 Chapter 2 General Policy 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. Rev 2002 2-3 Chapter 2 General Policy 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 Rev 2002 2-4 Chapter 2 General Policy 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. Rev 2002 2-5 Chapter 2 General Policy 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. Rev 2002 2-6 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. Rev 2002 2-7 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 Rev 2002 3-1 Chapter 3 Billing Policy 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. Rev 2002 3-2 Chapter 3 Billing Policy 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: Rev 2002 3-3 Chapter 3 Billing Policy 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. Rev 2002 3-4 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. 4-1 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