BULLETIN CHANGES AND CORRECTIONS TO THE MISSISSIPPI FEE SCHEDULE

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1 Mississippi Workers Compensation Commission 1428 Lakeland Drive / Post Office Box 5300 Jackson, Mississippi (601) Mike Marsh, Chairman Barney J. Schoby, Commissioner Beverly A. Bolton, Commissioner BULLETIN Medical Cost Containment Pat Dendy, Supervisor Please file this bulletin with your Fee Schedule and make the necessary changes to your current fee schedule which became effective 1/1/98 (medical) and 9/1/98 (hospital). CHANGES AND CORRECTIONS TO THE MISSISSIPPI FEE SCHEDULE On page 14, #III Reimbursement Guidelines, A. Other Practitioners, #1, add: Reimbursement will not be made for a Nurse Practitioner and a Physician for the same patient encounter. Payment will be made for one or the other, not both. Page 14, B. No Show, change to read: When an appointment is made by the employer/carrier for a Physician appointment and the claimant does not show, the provider may charge for a minimal office visit. Page 7, III Reimbursement, A. Instructions to Providers, add to #1: Physicians offices within the confines of a facility are paid the same as a Physician outside the facility. Facility fees are not appropriate for a physician office visit. PHARMACY GUIDELINES Page 17, D, please add the following: Dispensing fees are payable only if the prescription is filled under direct supervision of a registered pharmacist. On Page 20, E, RETROSPECTIVE REVIEW, please add the following: The results of this review should be forthcoming within 30 days after all information has been received. On Page 75, Assistant Surgeon Codes, add CPT code Co-Surgeon will be reimbursed at 125% of the Fee Schedule maximum allowable amount for that procedure and will be paid to the primary surgeon.

2 CORRECTIONS AND ADDITIONS TO HOSPITAL ADDENDUM On Page 8, item #9, Change to read: Inpatient Hospital Reimbursement is based on a per diem rate plus a per cent of the charges over and above the per diem amount. To calculate inpatient reimbursement, the following formula is applied: 1. Take total charges 2. Multiply number of inpatient days by the appropriate per diem rate and subtract that amount from total charges. 3. Review entire bill according to review guidelines and subtract any non-reimbursable charges from the total amount to get allowed total. 4. Subtract per diem from allowed total and multiply the remainder by 80% for the total allowed reimbursement for that admission. On page 9, item #10, change to read: All claims are subject to bill review for reasonable and necessary charges or fee schedule maximum allowances and guidelines.. On page 9, item #11, delete and replace with: When reviewing hospital claims, the following guidelines are to be followed: A. Most operative procedures require cardiopulmonary monitoring either by the physician performing the procedure or an anesthesiologist/anesthetist. Because these services are integral to the operating room environment, they are considered as part of the OR fee and are not separately reimbursed. The following items are not to be reimbursed separately: 1. Cardiac monitors 2. Oximetry 3. Blood pressure monitors 4. Lasers 5. Microscopes 6. Video equipment 7. Set up fees 8. Additional OR staff 9. Gowns 10. Gloves 11. Drapes 12. Towels 13. Mayo stand covers 14. On call or call back fees 15. After hour fees B. Billing for surgery packs as well as individual items in the packs is not allowed. C. A majority of invasive procedures require availability of vascular and/or airway access; therefore, the work associated with obtaining this access is included in the cost

3 of the service. i.e. anesthesia - Airway excess is associated with general anesthesia and is included in the anesthesia charges. D. Recovery room and ICU rates include the charge for cardiac monitoring and oximeter. It is assumed the patient is placed in these special areas for monitoring and specialized care which is bundled into the special care rate. Call back fees are not reimbursed for recovery room. E. Separate reimbursement is not allowed for setting up portable equipment at the patient s bedside. F. The following items do not qualify for separate reimbursement regardless of inpatient or outpatient status: 1. Applicators, cotton balls, band-aids 2. Syringes 3. Aspirin 4. Thermometers, blood pressure apparatus 5. Water pitchers 6. Alcohol preps 7. Ice bags On page 9, add the following as #13: Maximum reimbursement is set for the following line item charges: A. IV Pump/daily - $50.00 B. Venipuncture reimbursement is limited to $4.25 per collection. A collection fee is not appropriate for finger stick, throat culture, stool specimen collection. C. Pharmacy add-mixture/dispensing fee is limited to $4.50 per mixture. OUTPATIENT SERVICES Add the following CPT codes and ASC level of service to the hospital fee schedule Level Level Level Level Level Level Level Level Level Level Level Level Level Level 7

4 63016 Level Level Level Level Level Level Level Level Level Level Level Level Level Level Level Level Level Level Level Level Level Level Use the Technical Component for CPT for payment of this code Add the following to the Pain Management Section of the hospital schedule: Level Level 3 On Page 11, #5, add: The above list of services shall be reimbursed according to the Workers Compensation Fee Schedule or usual and customary reimbursement (for items not listed in the fee schedule.) On Page 14, add as #4 the following: Observation is not reimbursable for routine preparation furnished prior to an outpatient service or recovery after an outpatient service. Please refer to the criteria for observation services. On Page 15 of the Hospital Addendum under the Pain Management section, make the following changes: Delete CPT code and use for all levels paying at Level 3 Delete CPT code and use for nerve root injection only, not to include intercostal or other spinal nerves and pay at Level 4 Delete CPT code and use for all levels paying at Level 3 Add CPT code for all levels paying at Level 5 Add CPT code with payment at Level 1 On Page 11 of the Hospital Addendum under CODING AND BILLING RULES, please add the following: Pre-Admission lab and x-ray may be billed separate from the outpatient bill, when performed 24 hours or more prior to admission, and will be reimbursed the lesser of billed charges or the payment limit of the fee schedule. Pre-

5 admission lab and radiology are not included in the facility fees. On page 17, Radiology Services and Laboratory Services, delete and replace with the following: Facilities performing radiology and laboratory outpatient services will be reimbursed according to the Official Mississippi Workers Compensation Fee Schedule (lesser of billed charges or Official Workers Compensation Fee Schedule). The facility gets the technical portion and the physician gets the professional portion of the fee. On page 17, Emergency Room Services, delete and replace with the following: Emergency Room facility fees, supplies and treatment are reimbursed at a discount of 20% off billed charges. Radiology, lab and physician services are reimbursed according to the Official Mississippi Workers Compensation Fee Schedule. Outpatient diagnostic procedures (diskograms and mylegrams) and endoscopic procedures will be reimbursed as follows: The hospital will receive the technical component as listed in the Fee schedule for that procedure and the physician will receive the physician component. $100 for contrast materials can be paid when the CPT description does not indicate contrast material is included, GENERAL AMBULANCE SERVICES Ground Ambulance Transportation is reimbursed according to the fees and guidelines of the Mississippi Workers Compensation Fee Schedule. BILLING FOR AMBULANCE SERVICES 1. Report the appropriate HCFA Common Procedure Coding System (HCPCS) codes for each ambulance trip provided. In addition, report one of the mileage HCPC codes. Report only the above mentioned codes on the bill; one for the ambulance trip and one for the mileage. Each loaded (i.e. patient is on board) one-way ambulance trip will be billed. Unloaded trips and mileage are not to be reported. AMBULANCE REVENUE CODES 1. Revenue Code 540, General Classification, is used to report all ground ambulance transportation for work related injuries. Revenue Code 549 is used to report mileage (per mile). ORIGIN MODIFIERS 1. Report an origin modifier for each ambulance trip as follows: D. Diagnostic or therapeutic site E Residential, domiciliary, custodial facility

6 H P R S Hospital Physician s office Residence Scene of accident or acute event ALLOWABLE FEES HCPC CODE DESCRIPTION FEES A0320 Ambulance, basic life support (BLS), non emergency, supplies included, mileage separately billed $ A0322 Ambulance, BLS, emergency transport, supplies included, mileage separately $ A0324 Ambulance, advance life support (ALS), non emergency transport, no specialized ALS services rendered, supplies included, mileage separately billed $ A0326 Ambulance, ALS, non emergency, specialized ALS services rendered, supplies included, mileage billed separately $ A0328 Ambulance, ALS, emergency transport, no specialized ALS services rendered, supplies included, mileage separately billed $ A0330 Ambulance, ALS, emergency transport, specialized ALS services rendered, supplies included, mileage separately billed $ A0380 BLS mileage (per mile) $6.00 per mile A0390 ALS mileage (per mile) $6.00 per mile The appropriate ambulance fee includes the charges for supplies, monitoring equipment, and personnel. Medications may be billed separately and reimbursed according to Fee Schedule guidelines for pharmaceuticals. PAYMENT FOR AIR AMBULANCE Air ambulance transportation is reimbursed at a reasonable and customary rate for the area in which the service is provided. If a payer and provider can not reach an agreement on a reasonable rate, the Workers Compensation Commission will determine an appropriate reimbursement. Please forward all request for reimbursement determination to the Cost Containment Department. Page 17, add to Home Health: Outpatient Parenteral/Enteral Therapy Per Day Values listed below reflect the total allowance pr day and include necessary supplies for the safe and effective administration of the prescribed therapy. Supplies include Set(s), needles, syringes, saline, heparin, alcohol pads, start kits and catheters.

7 The allowance is calculated by adding the Drug and Ingredient Cost with the allowance per day: PARENTERAL DOSES DRUG/INGREDIENT ALLOWANCE PER DAY 1 AWP $ AWP $ AWP $ AWP $ or more AWP $ DESCRIPTION TPN PER DIEM RATE Liters $ Liters $ Liters or greater $ The above rates are for any combination of standard dextrose, amino acids and additives. LIPIDS DESCRIPTION Lipids 10% (500 mh) $75.00 Lipids 20% $95.00 PER DIEM RATES Daily per diem rates reflect I.V.pump with battery back-up alarm, pump administration sets, tubing, central line dressing kits, saline heparin, syringes, needles, PRN adapters, tape, gauges, IV poles and other supplies as needed. PAIN MANAGEMENT Allowances for pain management are for pain pump therapy (not to be confused with the outpatient pain management such as trigger points, epidural, etc.). DESCRIPTION PAIN MANAGEMENT MAX CHARGE PER DAY AWP of drug and ingredient $ Add cassettes 50 ML $ ML $50.00

8 HYDRATION 1 Liter/day $ Liters/day $ Liters/day $ Liters/day $ NUTRIENT ENTERAL THERAPY MAX CHARGE/DAY AWP $24.00 SUPPLIES AND EQUIPMENT Any supplies not listed in the Mississippi Fee Schedule will be reimbursed at cost plus 20%. An invoice is required for payment. Changes effectively immediately - 11/1/99

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