Fee Schedule Guidelines And Medical Services Rule 2015

Size: px
Start display at page:

Download "Fee Schedule Guidelines And Medical Services Rule 2015"

Transcription

1 Fee Schedule Guidelines And Medical Services Rule /01/ E Century Ave Ste 1 PO Box 5585 Bismarck ND

2 Copyright Notice The five character codes included in the North Dakota Fee Schedule are obtained from the Current Procedural Terminology (CPT), copyright 2014 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. The responsibility for the content of North Dakota Fee Schedules is with WSI and no endorsement by the AMA is intender or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in North Dakota Fee Schedule. Fee Schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Any use of CPT outside of North Dakota Fee Schedule should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply. CPT is a registered trademark of the American Medical Association. ADA codes are copyright 2014 American Dental Association. All Rights Reserved. Reproduced and distributed under ADA License #

3 Table of Contents Provider Remittance Advice... 2 Fee Schedule Parameters... 2 Definitions of Terms... 3 Dental Fee Schedule... 4 Durable Medical Equipment (DME) Schedule... 4 Anesthesia Fee Schedule... 5 Medical Fee Schedule... 5 Conversion Factor Table... 5 Pharmacy Fee Schedule... 6 Annual Updates... 7 WSI Specific Codes... 9 Payment Parameters Modifiers NOTE: For reference purposes, the sections of the North Dakota Administrative Code that regulate medical services are through The NDAC can be viewed at the North Dakota Legislative Council web site:

4 Provider Remittance Advice WSI processes medical service billings weekly. A remittance advice is sent to the provider with the reimbursement check, providing information to the provider about the service, including the patient's name, date of service, procedure billed, submitted, and paid. The remittance advice also includes reason codes or explanation of benefits (EOB) codes, to explain any reductions in payment of a service or denial of payment. Some EOB codes allow the patient to be billed for the denied charges, or for the balance of reduced charges. These instances are identified by the statement "CONTACT CLAIMANT FOR PAYMENT". When these EOB codes occur, WSI also sends a "NOTICE OF NON-PAYMENT" EOB to the patient regarding the reduced or denied charges, to inform the patient of their responsibility for the charges. If an EOB code does not state the patient may be contacted for payment, any reduction or denial of services is not billable to the patient, the employer, or another insurer. Copies of remittance advices can be obtained by calling You can access the list of our EOB codes on our website in the library section. Fee Schedule Parameters Reimbursement for services will be based on the established fee schedules. The appropriate fee schedule will apply to all providers, both in state and out of state, who are providing services to injured workers whose compensability is the responsibility of the North Dakota Workers Compensation system administered by Workforce Safety & Insurance (WSI). Disclaimer Langauage The fact that a procedure or service is assigned a HCPCS code and a payment rate does not imply coverage by WSI, but indicates only how the procedure or service may be paid if covered by the program. The existence of a procedure code on this list is not a guarantee that the code is covered.

5 Definitions of Terms BR RNE FUD PROF TECH By Report. Procedures denote BR (by report) in the unit value column indicate a variance too great to establish a relative value and will be reimbursed based on usual and customary review. Relativity Not Established. Procedures denoted RNE in the unit value column indicate a procedure that is new or uncommon and will be reimbursed based on usual and customary review. Follow-up days. Number of days for postoperative care when any subsequent care should be considered part of the original procedure. In the radiology, pathology/laboratory, and medicine sections of this manual, these figures identify relative values for the professional component of the service. In the radiology and pathology/laboratory sections of the fee schedule, these figures identify the relative values for the technical component of the service.

6 Dental Fee Schedule The dental fee schedule is based on CDT user s manual Current Dental Terminology. WSI will update the Dental Fee Schedule at least annually based on the Usual and Customary for the Fargo geographical area, zip code WSI will review procedures not listed in the fee schedule on a By Report basis and if accepted, will pay 85% of billed charges WSI pays the lesser of billed charges or the fee schedule. The WSI dental fee schedule will apply to all providers, both in state and out of state. Durable Medical Equipment (DME) Schedule WSI shall reimburse durable medical equipment (DME) as follows: WSI shall reimburse all HCPCS (Common Procedure Coding System) codes listed in the Medicare fee schedule for North Dakota at Medicare s North Dakota Schedule plus 20%. WSI shall reimburse all HCPCS codes not listed in the Medicare schedule for North Dakota at the 50 th percentile of the usual, customary and reasonable rate (UCR) of the geographic area. In the absence of a UCR rate, WSI shall reimburse at an 85% cost-to-charge ratio. WSI shall limit the monthly rental payments for Capped Rental items to 13 months. WSI shall pay for capped rental items that are approved for purchase using the following formula: 100% of the monthly rental X 3 plus 75% of the monthly rental X 10 The purchase s for capped rental items are identified in the DME fee schedule with a modifier of NU. WSI shall only reimburse for electromedical equipment and related supplies covered by the following HCPCS codes under a preferred provider agreement: (PPA): A4556 A4557 A4455 A4558 A6250 Electrodes Lead wires Adhesive remover Paste or gel Vitamin lotion A4245 A4630 E0720 E0730 E0745 Alcohol wipes Batteries Tens two lead Tens four lead Neuromuscular stimulator WSI shall pay in full any charges submitted that are less than or equal to the maximum allowable fee.

7 Anesthesia Fee Schedule WSI shall use the following formula to determine the maximum allowable fee for anesthesia: Basic Time Physical Conversion Maximum value + units + status x factor = Reimbursement units modifier One time unit equals 15 minutes, regardless of the length of the procedure. Medical Fee Schedule The medical fee schedule uses the procedure codes and descriptions of the American Medical Association s physicians Current Procedural Terminology (CPT ). Fees are calculated using the Resource Based Relative Values (RBRVS) RVU weights established by the Centers for Medicare & Medicaid (CMS) The medical and hospital fee schedules contain the entire list of CPT identifying codes. The listing of CPT codes in the fee schedules is not a guarantee of payment. WSI shall use the following conversion factor table to determine the maximum allowable fee by multiplying the conversion factor by the relative value unit established in the RBRVS. Conversion Factor Table Specialty Groups Conversion Factor Anesthesia (Time Units & Risk Units) Evaluation and Management Medicine Physical & Occupational Therapy Radiology Professional Radiology (only) Pathology Surgery Clinic Laboratory 2.5 x ND Medicare schedule

8 Pharmacy Fee Schedule The pharmacy fee schedule is based on Wolters Kluwer Medispan Electronic Drug file wholesale acquisition price (WAC) for all national drug codes (NDC.) The pharmacy fee schedule for maximum allowable cost (MAC) is based on the most current MAC list provided by US Script, Inc. WSI reimburses for prescribed brand name drugs at the WAC plus 8%, plus a single per item dispensing fee of $4.00. WSI reimburses for generic drugs at the lesser of MAC plus 5% or WAC plus 8%, plus a single per item dispensing fee of $5.00. WSI pays in full any charges submitted that are less than or equal to the maximum allowable fee. Charges for Durable Medical Equipment (DME) or supply items (i.e. gauze, tape, etc.) need to be submitted to WSI in paper format or electronically in the CMS 1500 format. Compound Medication WSI reimburses for compounded prescriptions at average wholesale price (AWP) minus 72%, plus a single item compounding fee based on the following level of effort (LOE) level: Compound LOE Value Reimbursement Level 1 11 $10.00 Level 2 12 $15.00 Level 3 13 $20.00 Level 4 14 $25.00 Level 1: Mixing liquids using graduated cyclinders. Level 2: Triturate powder and mix by geometric dilution, mix creams, ointments, emulsions, and liquids by hand or by using unguator. Level 3: Suppository mold, lollipop mold, and troche/mini-troche mold, dissolve powder using stirrer and hot plate, melt base on hot plate, burette and/or ph meter, making capsules using capsule filling machine. Level 4: USP 797, sterile compounding using hood

9 Annual Updates Medical Fee Schedule WSI will update the Medical Fee Schedule conversion factor each year based on the Medicare Economic Index (MEI) for physician services published each year in the Physician Fee Schedule final rule. Appropriate adjustments will be made for RVU weight changes (if necessary). The update to the conversion factor will be applied to the separate Anesthesia conversion factor. Inpatient Acute Hospital Fee Schedule WSI will update the Inpatient Hospital Fee Schedule base rate each year based on the hospital Market Basket increase published by Medicare in the Inpatient Prospective Payment System final rule. Appropriate adjustments will be made for DRG weight changes (if necessary). If a separate Market Basket is published for capital costs, that update will be applied to the capital portion of the base rate. If a separate Market Basket is not published for capital costs, the operating cost update will be applied to both the operating portion and the capital portion of the base rate. The outlier target for each year is set at an equal to 10% of the estimated DRG plus outlier payments. Estimated DRG payments are based on claims paid between January 1 and September 30 th of the current year. When determining the outlier target and threshold, those cases where the actual outlier payments were greater than $100,000 will be eliminated from the database of claims. The following year s conversion factor is multiplied by the following year s weights to arrive at estimated DRG payments. Based on the same claims database and a marginal payment factor of 80%, the current year s outlier threshold is raised or lowered until anticipated outlier payments equal 10% of total DRG payments plus anticipated outlier paymnets. The outlier threshold is rounded to the nearest $500. Outlier Threshold for year 2012 is $90,000. Outpatient Hospital Fee Schedule WSI will update the Outpatient Hospital Fee Schedule conversion factor each year based on the hospital Market Basket increase published by CMS in the Outpatient Prospective Payment System final rule. Appropriate adjustments will be made for ambulatory payment classification (APC) weight changes (if necessary). Ambulatory Surgical Center Fee Schedule WSI will update the Ambulatory Surgical Center Fee Schedule conversion factor each year based on the hospital Market Basket increase published by CMS in the Outpatient Prospective Payment System final rule. Appropriate adjustments will be made for the APC weight changes (if necessary).

10 Ambulance Fee Schedule WSI will update the Ambulance Fee Schedule each year based on the CPI-U published by CMS. The increase will be applied to the prior year s payment s. The update will apply to both ground ambulance services and air ambulance services. Appropriate adjustments will be made for base rate weight changes (if necessary). Home Health Fee Schedule WSI will update the Home Health Fee Schedule each year based on the Home Health Market Basket increase published by Medicare in the Home Health Agency final rule. The update percent will be applied to both the Home Care per visit payment s and the Home Care hourly payment s. The increase in any one year will be limited to 4.5%. If WSI believes an increase of greater than 4.5% is warranted, the increase will be sought through the informal public hearing process. Likewise, if a neutral (0) or decrease (less than 0) change in fee schedule is warranted, after adjustments for the RVU weights, input will be sought though the informal public hearing proces

11 WSI Specific Codes These codes replace non-descriptive CPT codes or when a CPT did not have a code established for services. The diagram below outlines the code, the intended use for the code, and the reimbursement level for each code. WSI Code Code Description Long Description W0200 Telephone call Telephone call between health care provider and employer with employer for issues related to work restrictions Billable in addition to an E & M charge Documentation in medical notes required regarding the telephone call and time spend W0300 WSI Case Face to face discussion with a WSI Medical Case Manager Visit Manager, prior to, during or after injured worker office visit Documentation in medical notes required W0310 Vocational Case Face to face discussion with a Vocational Case Manager, Managers prior to, during or after injured worker office visit Documentation in medical notes required W0400 Fluidotherapy. Application of a modality to one or more areas Documentation in medical notes required outlining the body area and time W0410 Phonopheresis Application of a modality to one or more areas. Documentation in medical notes required outlining the body area and time W0500 Independent Examination conducted on an injured worker at the Medical request of WSI Examination Detailed report required to be submitted to WSI Fee Schedule Amount $59.09 $ $ $43.22 per 15 minutes $61.08 per 15 minutes 100% of billed W0510 W0520 Independent Medical Examination no show Independent Medical Review No-show reimbursement for scheduled IME when injured worker does not present to the IME appointment A review of injured workers records Detailed report required to be submitted to WSI 100% of billed 100% of billed W0540 Functional Capacity Evaluation Objective, directly observed, measurement of an injured worker s ability to perform a variety of physical tasks combined with subjective analyses of abilities by the claimant and the evaluator. A physical tolerance screening and a Blankenship s functional evaluation are functional capacity evaluations. Detailed report required to be submitted to WSI 100% of billed

12 WSI Code W0545 Code Description Functional Capacity Evaluation no show Long Description No-show reimbursement for scheduled FCE when injured worker does not present to the FCE appointment W0550 Job Site Analysis Report of injured worker's job duties at time of injury Detailed report required to be submitted to WSI Excludes JA done with the Ego inititive grant program Fee Schedule Amount 100% of billed *100% of billed when approved by claims adjuster W0555 Independent Exercise Exercise program designed to improve overall cardiovascular, pulmonary, and neuromuscular condition of the injured worker prior to or in conjunction with return to work; prior approval required Detailed report required to be submitted to WSI 100% of billed W0560 Permanent Partial Impairment (PPI) Evaluation A detailed clinical report supporting the percentage rating of injury to whole body impairment and apportionment between work and non-work related if appropriate. 100% of billed W0561 PPI medical records review Review of medical records in PPI evaluation 100% of billed W0562 PPI report Compose PPI report 100% of billed W0563 Travel-PPI Per mile cost of PPI evaluator traveling to PPI examination site $.575 per mile. Established each January 1 st and reimbursed at US General Services W0564 PPI- Lodging Cost of lodging of PPI evaluator traveling to PPI examination site W0565 PPI Meals Cost of meals of PPI evaluator traveling to PPI examiniation site Administration rate. $83.00 per night. Estabished each January 1 st and reimbursed at US General Service Administration rate. $35 per day. Established each January 1 st and reimbursed at state rates W0566 PPI Facility Cost of facility rental for conducting PPI 100% of billed rental W0567 PPI No show No-show reimbursement for scheduled PPI evaluation and injured worker does not present to the PPI appointment 100% of billed

13 Payment Parameters 1. The WSI physician fee schedule will be a true fee schedule WSI will pay the lesser of billed charges or the fee schedule. 2. WSI will update the Medical Fee Schedule conversion factor each year based on the Medicare Economic Index (MEI) for physician services published each year in the Physician Fee Schedule final rule. Appropriate adjustments will be made for RVU weight changes (if necessary). The update to the conversion factor will be applied to the separate Anesthesia conversion factor. 3. WSI will adopt Medicare s published Relative Value Units (RVUs) for each year (including quarterly updates). If both Transitioned and Fully Implemented RVU s are published, WSI will use the Transitioned RVU s. 4. WSI will incorporate Medicare s definitions and use of facility and non-facility sites of service. Services provided in a non facility setting will be paid using Medicare s non facility RVUs. Services provided in a facility setting will be paid using Medicare s facility RVUs. 5. When Medicare publishes annual updates to the RVU weights, WSI will incorporate any transitional weight s. 6. There will be no adjustments to RVU weights for Geographic Practice Cost Indices (GPCI), for the work RVU floor or for other RVU adjustments except for transitional periods applied to base RVU s. 7. There will be no payment reduction for mid level practitioners (NP, PA, CNS, Nurse Midwife, Clinical Psychologist, LCSW and CRNA). 8. The WSI physician fee schedule s will apply to all providers, both in state and out of state. 9. For those HCPCS codes with no published RVUs, payment determinations will be made based on the Ingenix regional usual and customary charge data. 10. There will be no payment reductions for radiology services provided by Chiropractors. 11. WSI will not incorporate Medicare s payment reductions for the technical portions or professional portions of radiology services when multiple procedures in the same radiology family are performed on the same day. 12. WSI will not incorporate Medicare s payment reductions for multiple endoscopy procedures. Medicare s multiple surgical procedure payment reductions will apply to multiple endoscopy procedures. 13. WSI will adopt Medicare s payment reductions for the technical portion of diagnostic radiology services. The payment for the technical portion of diagnostic radiology services under the Medical Fee Schedule will be limited to the payment under the Hospital Outpatient Fee Schedule.

14 14. WSI will assign one of 4 status codes to each HCPCS code. The following status codes will be used: A Active Code Will be paid under the WSI fee schedule B Bundled Code Payment is bundled into the payment for other services C WSI Priced Code Payment is made under WSI negotiated s or U&C s P Excluded Code No payment is made for these codes The following crosswalk will be used: RVU Table Indicator A B C D E F G H I M N P R T X WSI Indicator A B C P A, C or P P A P A, C or P P A or C P A or C A or C A, C or P 15. WSI will incorporate Medicare s global surgical periods and global surgical payment policies. Procedures subject to either the 10 or 90 day global periods are those published by Medicare in the annual RVU table. When WSI requests a visit with a patient during a global period, that visit can be paid separately if billed with modifier 32. The services would be separately paid under the Medical Fee Schedule. The following indicators will be assigned to each HCPCS code: 000 No global period day global period day global period The following crosswalk will be used: RVU Table WSI Indicator Indicator MMM 000 XXX 000 YYY 000 ZZZ 000

15 16. WSI will adopt Medicare s percentages for pre operative, operative and post operative payments and require the use of the appropriate modifiers (56 preoperative care only, 54 surgical care only, 55 postoperative care only). 17. WSI will adopt Medicare s multiple procedure discounts for most procedures. The following indicators will be assigned to each HCPCS code: 0 No adjustment rules applied 2 Standard payment adjustment rules applied (100%, 50%, 50%.) The following crosswalk will be used: RVU Table WSI Indicator Indicator WSI will adopt Medicare s bilateral surgery payment adjustments for services billed with Modifier 50. The following indicators will be assigned to each HCPCS code: 0 bilateral procedure payment adjustment does not apply 1 150% bilateral procedure payment adjustment applies The following crosswalk will be used: RVU Table WSI Indicator Indicator

16 19. WSI will adopt Medicare s assistant at surgery payment policies. The policies will apply to both physicians (modifiers 80-82) and mid-levels (modifier AS). WSI will allow assistants at surgery for those HCPCS codes that Medicare has indicated as appropriate for assistant at surgery payments. The following indicators will be assigned to each HCPCS code: 1 Assistant at surgery payments are not permitted for this procedure 2 Assistant at surgery payments are permitted for this procedure The following crosswalk will be used: RVU Table Indicator WSI Indicator WSI will adopt Medicare s co-surgeon payment policies. WSI will allow co-surgeon billings and payment for those HCPCS codes that Medicare has indicated as appropriate for co-surgeon payments. The following indicators will be assigned to each appropriate HCPCS code: 0 Co-surgeons are not permitted for this procedure 1 Co-surgeons are permitted for this procedure The following crosswalk will be used: RVU Table WSI Indicator Indicator WSI will not adopt Medicare s team surgery payment policy and will not pay for services billed with Modifier WSI will not adopt Medicare s bundling provisions that apply to T status codes. These codes will continue to receive separate payment when reported with other services. 23. WSI will adopt the National Correct Coding Initiative (NCCI) edits. 24. WSI will accept all Level I and II modifiers on claim forms. Those that are not used for payment modifications will be ignored by the system.

17 Modifiers When applicable, the modifying circumstances against general guidelines should be identified by the addition of the appropriate modifier code, and are reimbursed as follows: Anesthesia by Surgeon (47) No reimbursement in addition to base payment Bilateral Procedure secondary procedure (50) 100% of fee schedule (1 st procedure) 50% of fee schedule (2 nd procedure) Multiple Procedures (51) The major or primary procedure is reimbursed at 100% of fee schedule, any additional procedure is reimbursed at 50% of fee schedule Discontinued Procedure (53) The reimbursement rate will be 50% of the fee schedule Surgical Care Only (54) Medicare s percentage based on individually assigned weights Postoperative Management only (55) Medicare s percentage based on individually assigned weights Pre-Operative Care Only (56) Medicare s percentage based on individually assigned weights Distint Procedural Service (59) 100% of fee schedule with the appropriate multiple procedure discounts Assistant Surgeon (80, 82, AS) Any Physician or non-physician assisting another physician in surgery is reimbursed at 16% of fee schedule. Co-Surgeons (62) Based on allowed indicator, 62.5% of fee schedule for each surgeon, if allowed Waiver of Liability Statement on file (GA) No reimbursement allowed. Patient will be responsible for the charges.

Pennsylvania Workers Compensation Billing Tutorial. Step 1: Find the Charge Classes by Zip Code

Pennsylvania Workers Compensation Billing Tutorial. Step 1: Find the Charge Classes by Zip Code Step 1: Find the Charge Classes by Zip Code http://www.portal.state.pa.us/portal/server.pt/community/charge_classes_by_zip_co de/10428 The Pennsylvania Workers' Compensation Fee Schedule for Part B providers

More information

IWCC 50 ILLINOIS ADMINISTRATIVE CODE 7110 7110.90. Section 7110.90 Illinois Workers' Compensation Commission Medical Fee Schedule

IWCC 50 ILLINOIS ADMINISTRATIVE CODE 7110 7110.90. Section 7110.90 Illinois Workers' Compensation Commission Medical Fee Schedule Section 7110.90 Illinois Workers' Compensation Commission Medical Fee Schedule a) In accordance with Sections 8(a), 8.2 and 16 of the Workers' Compensation Act [820 ILCS 305/8(a), 8.2 and 16] (the Act),

More information

RULES OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF WORKERS COMPENSATION CHAPTER 0800-02-18 MEDICAL FEE SCHEDULE

RULES OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF WORKERS COMPENSATION CHAPTER 0800-02-18 MEDICAL FEE SCHEDULE RULES OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF WORKERS COMPENSATION CHAPTER 0800-02-18 MEDICAL FEE SCHEDULE TABLE OF CONTENTS 0800-02-18-.01 Medicare-Basis for System, Applicability,

More information

The following is a description of the fields that appear on the results page for the Procedure Code Search.

The following is a description of the fields that appear on the results page for the Procedure Code Search. Fee Schedule Legend Updated: 9/21/2015 The following is a description of the fields that appear on the results page for the Procedure Code Search. Procedure Code the five-character procedure code as listed

More information

GEORGIA. The MEDICAL FEE SCHEDULE WORKERS' COMPENSATION. Effective 04/01/2011 FOR SERVICES PROVIDED UNDER THE GEORGIA WORKERS' COMPENSATION LAW

GEORGIA. The MEDICAL FEE SCHEDULE WORKERS' COMPENSATION. Effective 04/01/2011 FOR SERVICES PROVIDED UNDER THE GEORGIA WORKERS' COMPENSATION LAW The GEORGIA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE Effective 04/01/2011 FOR SERVICES PROVIDED UNDER THE GEORGIA WORKERS' COMPENSATION LAW Adopted by: State Board of Workers' Compensation 270 Peachtree

More information

Rotator Cuff Repair Surgical Procedures

Rotator Cuff Repair Surgical Procedures Rotator Cuff Repair Surgical Procedures 2011 Reimbursement and Coding Reference Guide for Physicians and Hospitals This coding reference guide is intended to illustrate the common CPT * codes, ICD-9 CM

More information

Medical Practitioner Reimbursement

Medical Practitioner Reimbursement INDIANA HEALTH COVERAGE PROGRAMS PROVIDER REFERENCE M ODULE Medical Practitioner Reimbursement L I B R A R Y R E F E R E N C E N U M B E R : P R O M O D 0 0 0 1 6 P U B L I S H E D : F E B R U A R Y 25,

More information

Subtitle 09 WORKERS' COMPENSATION COMMISSION. 14.09.03 Guide of Medical and Surgical Fees

Subtitle 09 WORKERS' COMPENSATION COMMISSION. 14.09.03 Guide of Medical and Surgical Fees Subtitle 09 WORKERS' COMPENSATION COMMISSION 14.09.03 Guide of Medical and Surgical Fees Authority: Labor and Employment Article, 9-309, 9-663 and 9-731, Annotated Code of Maryland Notice of Proposed Action

More information

Global Surgery Fact Sheet

Global Surgery Fact Sheet DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services R Global Surgery Fact Sheet Fact Sheet Definition of a Global Surgical Package Medicare established a national definition

More information

Workers Compensation. All Service Types. Milliman Client Report. Prepared for: Nevada Division of Industrial Relations

Workers Compensation. All Service Types. Milliman Client Report. Prepared for: Nevada Division of Industrial Relations Milliman Client Report Workers Compensation All Service Types Prepared for: Nevada Division of Industrial Relations TABLE OF CONTENTS 1. Introduction...... 3 2. Physician Benchmarking and Recommendations

More information

Medicare 101: Basics of Modifier Billing. Part B Provider Outreach and Education February 26, 2014

Medicare 101: Basics of Modifier Billing. Part B Provider Outreach and Education February 26, 2014 Medicare 101: Basics of Modifier Billing Part B Provider Outreach and Education February 26, 2014 Housekeeping Tips When you called in, did you enter your attendee code? Dial-in number: 1-800-791-2345

More information

The emergency amendment of 8 AAC (m) is made permanent to read:

The emergency amendment of 8 AAC (m) is made permanent to read: The emergency repeal of 8 AAC 45.082(l)(2) is made permanent: (2) repealed 12/1/2015; The emergency amendment of 8 AAC 45.082(m) is made permanent to read: (m) A fee or other charge for medical treatment

More information

ILLINOIS WORKERS' COMPENSATION COMMISSION MEDICAL FEE SCHEDULE INSTRUCTIONS AND GUIDELINES

ILLINOIS WORKERS' COMPENSATION COMMISSION MEDICAL FEE SCHEDULE INSTRUCTIONS AND GUIDELINES Table of Contents ILLINOIS WORKERS' COMPENSATION COMMISSION MEDICAL FEE SCHEDULE INSTRUCTIONS AND GUIDELINES For treatment before 2/1/09 Introduction and Purpose Reference Materials Section 1. Ambulatory

More information

Fact Sheet on the Resource Based Relative Value Scale (RBRVS) Fee Schedule Effective January 1, 2014

Fact Sheet on the Resource Based Relative Value Scale (RBRVS) Fee Schedule Effective January 1, 2014 Fact Sheet on the Resource Based Relative Value Scale (RBRVS) Fee Schedule Effective January 1, 2014 1. When did the new RBRVS-based fee schedule become effective? 1.1. The RBRVS-based physician and non-physician

More information

New Mexico Workers Compensation Administration

New Mexico Workers Compensation Administration New Mexico Workers Compensation Administration Fee Schedule and Billing Instructions Effective: December 31, 2013 Susana Martinez, Governor Darin A. Childers, WCA Director P.O. Box 27198 * Albuquerque,

More information

2013 MPFS Indicator Descriptors

2013 MPFS Indicator Descriptors 2013 MPFS Indicator Descriptors Here is an overview of the layout. Use the key on the following pages to interpret indicators. Indicator NOTE - # NOTE - C PROCEDURE/MOD PAR Amount NON-PAR Amount Limiting

More information

Suzanne Honor-Vangerov, Esq. CPC, CPC-I

Suzanne Honor-Vangerov, Esq. CPC, CPC-I Suzanne Honor-Vangerov, Esq. CPC, CPC-I 1 Managing Attorney, Lien Unit Floyd Skeren & Kelly LLP Owner of Honor System Consulting Prior Manager of the Division of Workers Compensation Medical Unit, in charge

More information

MODIFIERS. Original Effective Date: July 7, 2009 Revision Date: February 1 st, 2014

MODIFIERS. Original Effective Date: July 7, 2009 Revision Date: February 1 st, 2014 Original Effective Date: July 7, 2009 Revision Date: February 1 st, 2014 MODIFIERS Policy s are used to increase accuracy in recording patient encounters and compensation. A modifier provides the means

More information

WORKERS' COMPENSATION MEDICAL FEE SCHEDULE RULE 40.000

WORKERS' COMPENSATION MEDICAL FEE SCHEDULE RULE 40.000 WORKERS' COMPENSATION MEDICAL FEE SCHEDULE RULE 40.000 40.000 Workers' Compensation Medical Fee Schedule The five-digit numeric codes and descriptions included in Rule 40.000, Medical Fee Schedule, are

More information

Physician Fee Schedule BCBSRI follows CMS Physician Fee Schedule (PFS) Relative Value Units (RVU) for details relating to

Physician Fee Schedule BCBSRI follows CMS Physician Fee Schedule (PFS) Relative Value Units (RVU) for details relating to Policy Coding and Guidelines EFFECTIVE DATE: 09 01 2015 POLICY LAST UPDATED: 09 02 2015 OVERVIEW This Policy provides an overview of coding and guidelines as they pertain to claims submitted to Blue Cross

More information

1) There are 0 indicator edits, which are never correctly reported together;

1) There are 0 indicator edits, which are never correctly reported together; Medical Coverage Policy Coding and Guidelines sad EFFECTIVE DATE: 11/15/2011 POLICY LAST UPDATED: 11/1/2013 OVERVIEW This Policy provides an overview of coding and guidelines as they pertain to claims

More information

MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS

MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS Chapter 5: MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS SUMMARY: This Chapterchapter outlines billing procedures and reimbursement levels for health care providers who treat injured employees.

More information

Payment Methodology Grid for Medicare Advantage PFFS/MSA

Payment Methodology Grid for Medicare Advantage PFFS/MSA Payment Methodology Grid for Medicare Advantage PFFS/MSA This applies to SmartValue and Security Choice Private Fee-for-Service (PFFS) plans and SmartSaver and Save Well Medical Savings Account (MSA) plans.

More information

CODING. Neighborhood Health Plan 1 Provider Payment Guidelines

CODING. Neighborhood Health Plan 1 Provider Payment Guidelines CODING Policy The terms of this policy set forth the guidelines for reporting the provision of care rendered by NHP participating providers, including but not limited to use of standard diagnosis and procedure

More information

STATE OF NEVADA DEPARTMENT OF BUSINESS & INDUSTRY DIVISION OF INDUSTRIAL RELATIONS WORKERS COMPENSATION SECTION

STATE OF NEVADA DEPARTMENT OF BUSINESS & INDUSTRY DIVISION OF INDUSTRIAL RELATIONS WORKERS COMPENSATION SECTION STATE OF NEVADA DEPARTMENT OF BUSINESS & INDUSTRY DIVISION OF INDUSTRIAL RELATIONS WORKERS COMPENSATION SECTION NEVADA MEDICAL FEE SCHEDULE MAXIMUM ALLOWABLE PROVIDER PAYMENT February 1, 2012 through January

More information

Modifier Reference PAYMENT POLICY ID NUMBER: 10-011. Original Effective Date: 05/14/10. Revised: 05/31/12 DESCRIPTION:

Modifier Reference PAYMENT POLICY ID NUMBER: 10-011. Original Effective Date: 05/14/10. Revised: 05/31/12 DESCRIPTION: Private Property of Florida Blue. This payment policy is Copyright 2012, Florida Blue. All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission

More information

CODE AUDITING RULES. SAMPLE Medical Policy Rationale

CODE AUDITING RULES. SAMPLE Medical Policy Rationale CODE AUDITING RULES As part of Coventry Health Care of Missouri, Inc s commitment to improve business processes, we are implemented a new payment policy program that applies to claims processed on August

More information

Status Active. Assistant Surgeons. This policy addresses reimbursement for assistant surgical procedures during the same operative session.

Status Active. Assistant Surgeons. This policy addresses reimbursement for assistant surgical procedures during the same operative session. Status Active Reimbursement Policy Section: Surgery/Interventional Procedure Policy Number: RP - Surgery/Interventional Procedure - 001 Assistant Surgeons Effective Date: June 1, 2015 Assistant Surgeons

More information

General Information (Chapters 1-5) outlines the general policies and procedures applicable to all providers and payers.

General Information (Chapters 1-5) outlines the general policies and procedures applicable to all providers and payers. 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

More information

Medicare Outpatient Therapy Billing

Medicare Outpatient Therapy Billing DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services R Medicare Outpatient Therapy Billing August 2010 / ICN: 903663 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare

More information

National Correct Coding Initiative Policy Manual for Medicare Services Revision Date: January 1, 2014

National Correct Coding Initiative Policy Manual for Medicare Services Revision Date: January 1, 2014 National Correct Coding Initiative Policy Manual for Medicare Services Revision Date: January 1, 2014 Current Procedural Terminology 2013 American Medical Association. All Rights Reserved. Current Procedural

More information

Empire BlueCross BlueShield Professional Reimbursement Policy

Empire BlueCross BlueShield Professional Reimbursement Policy Subject: Modifier Rules NY Policy: 0017 Effective: 02/01/2014 06/30/2014 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria

More information

Health Care Services Manual (Fee Schedule)

Health Care Services Manual (Fee Schedule) State of Michigan Workers' Compensation Agency Health Care Services Manual (Fee Schedule) Effective: February 20, 2004 Department of Labor & Economic Growth State of Michigan 7150 Harris Drive PO Box 30016

More information

FREQUENTLY ASKED QUESTIONS

FREQUENTLY ASKED QUESTIONS FREQUENTLY ASKED QUESTIONS OFFICAL MEDICAL FEE SCHEDULE (OMFS), INPATIENT HOSPITAL FEE SCHEDULE (IHFS) AND MEDICAL-LEGAL FEE SCHEDULE (MLFS) How do I get an Official Medical Fee Schedule book and how much

More information

ANESTHESIA PAYMENT GUIDELINES. 1) Basic Value (which relates to the complexity of the service); and 2) Time Units; and 3) Modifying Units (if any).

ANESTHESIA PAYMENT GUIDELINES. 1) Basic Value (which relates to the complexity of the service); and 2) Time Units; and 3) Modifying Units (if any). ANESTHESIA PAYMENT GUIDELINES Only a single payment for anesthetic services will be made for a single operative session. For example, there will be no additional payment made for the services of certified

More information

CLAIM FORM REQUIREMENTS

CLAIM FORM REQUIREMENTS CLAIM FORM REQUIREMENTS When billing for services, please pay attention to the following points: Submit claims on a current CMS 1500 or UB04 form. Please include the following information: 1. Patient s

More information

Title 8, California Code of Regulations, 9789.30 et seq.

Title 8, California Code of Regulations, 9789.30 et seq. Title 8, California Code of Regulations Chapter 4.5, Division of Workers Compensation Subchapter 1 Administrative Director-Administrative Rules Article 5.3 Official Medical Fee Schedule-Hospital Outpatient

More information

INTRODUCTION. The Workers Compensation Act provides in part as follows:

INTRODUCTION. The Workers Compensation Act provides in part as follows: INTRODUCTION The Maryland Workers Compensation Commission (Commission) amended COMAR 14.09.03.01 (Guide of Medical and Surgical Fees) on February 12, 2004. AUTHORITY The Workers Compensation Act provides

More information

Local Coverage Article: Cardiovascular Stress Testing (A53123)

Local Coverage Article: Cardiovascular Stress Testing (A53123) Local Coverage Article: Cardiovascular Stress Testing (A53123) Contractor Information Contractor Name Novitas Solutions, Inc. Article Information General Information Article ID A53123 Original ICD-9 Article

More information

ILLINOIS WORKERS' COMPENSATION COMMISSION MEDICAL FEE SCHEDULE INSTRUCTIONS AND GUIDELINES FOR TREATMENT ON OR AFTER 2/1/09

ILLINOIS WORKERS' COMPENSATION COMMISSION MEDICAL FEE SCHEDULE INSTRUCTIONS AND GUIDELINES FOR TREATMENT ON OR AFTER 2/1/09 ILLINOIS WORKERS' COMPENSATION COMMISSION MEDICAL FEE SCHEDULE INSTRUCTIONS AND GUIDELINES FOR TREATMENT ON OR AFTER 2/1/09 Revised 5/14/10: Outdated text referring to old DRG codes on page 7 deleted Revised

More information

DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS WORKERS COMPENSATION AGENCY WORKERS COMPENSATION HEALTH CARE SERVICES

DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS WORKERS COMPENSATION AGENCY WORKERS COMPENSATION HEALTH CARE SERVICES DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS WORKERS COMPENSATION AGENCY WORKERS COMPENSATION HEALTH CARE SERVICES Filed with the Secretary of State on December 17, 2014 These rules take effect 7 days

More information

Local Coverage Article: Venipuncture Necessitating Physician s Skill for Specimen Collection Supplemental Instructions Article (A50852)

Local Coverage Article: Venipuncture Necessitating Physician s Skill for Specimen Collection Supplemental Instructions Article (A50852) Local Coverage Article: Venipuncture Necessitating Physician s Skill for Specimen Collection Supplemental Instructions Article (A50852) Contractor Information Contractor Name CGS Administrators, LLC Article

More information

Medicare Physician Fee Schedule Modifiers

Medicare Physician Fee Schedule Modifiers Basics of MPFS Part 3 Medicare Physician Fee Schedule Modifiers Presented by Part B Provider Outreach and Education July 16, 2013 Disclaimer This information released is the property of Cahaba GBA and

More information

Glossary. Adults: Individuals ages 19 through 64. Allowed amounts: See prices paid. Allowed costs: See prices paid.

Glossary. Adults: Individuals ages 19 through 64. Allowed amounts: See prices paid. Allowed costs: See prices paid. Glossary Acute inpatient: A subservice category of the inpatient facility clams that have excluded skilled nursing facilities (SNF), hospice, and ungroupable claims. This subcategory was previously known

More information

WELLCARE CLAIM PAYMENT POLICIES

WELLCARE CLAIM PAYMENT POLICIES WellCare and Harmony Health Plan s claim payment policies are based on publicly distributed guidelines from established industry sources such as the Centers for Medicare and Medicaid Services (CMS), the

More information

Introduction to the Rhode Island Workers Compensation Fee Schedule

Introduction to the Rhode Island Workers Compensation Fee Schedule Introduction to the Rhode Island Workers Compensation Fee Schedule Each year an attempt is made to expand and clarify the Rhode Island Workers Compensation Fee Schedule. Significant effort went into making

More information

2015 Schedule of Medical Fees

2015 Schedule of Medical Fees 2015 Schedule of Medical Fees Kansas Workers Compensation Kansas Department of Labor DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Topeka, KS 66603 KANSAS DEPARTMENT OF LABOR DIVISION OF WORKERS

More information

(I) The following prescribed drugs are included: (a) drugs, which require a prescription, except for those drugs specifically excluded;

(I) The following prescribed drugs are included: (a) drugs, which require a prescription, except for those drugs specifically excluded; Description of Service Limitations Attached Sheet to Attachment 3.1 A Page 3 9. CLINIC SERVICES: "Clinic Services" means services provided by state-approved outpatient community mental health clinics that

More information

SUBCHAPTER 29. MEDICAL FEE SCHEDULES: AUTOMOBILE INSURANCE PERSONAL INJURY PROTECTION AND MOTOR BUS MEDICAL EXPENSE INSURANCE COVERAGE

SUBCHAPTER 29. MEDICAL FEE SCHEDULES: AUTOMOBILE INSURANCE PERSONAL INJURY PROTECTION AND MOTOR BUS MEDICAL EXPENSE INSURANCE COVERAGE SUBCHAPTER 29. MEDICAL FEE SCHEDULES: AUTOMOBILE INSURANCE PERSONAL INJURY PROTECTION AND MOTOR BUS MEDICAL EXPENSE INSURANCE COVERAGE 11:3-29.1 Purpose and scope (a) This subchapter implements the provisions

More information

BULLETIN CHANGES AND CORRECTIONS TO THE MISSISSIPPI FEE SCHEDULE

BULLETIN CHANGES AND CORRECTIONS TO THE MISSISSIPPI FEE SCHEDULE Mississippi Workers Compensation Commission 1428 Lakeland Drive / Post Office Box 5300 Jackson, Mississippi 39296-5300 (601) 987-4268 http://www.mwcc.state.ms.us Mike Marsh, Chairman Barney J. Schoby,

More information

Reimbursement Policy. Policy

Reimbursement Policy. Policy Reimbursement Policy Subject: Modifier Usage Effective Date: 03/14/13 Committee Approval Obtained: 09/22/14 Section: Coding These policies serve as a guide to assist you in accurate claim submissions and

More information

410-130-0005 Federally Qualified Primary Care Provider NEW RULE

410-130-0005 Federally Qualified Primary Care Provider NEW RULE 410-130-0005 Federally Qualified Primary Care Provider NEW RULE Federally Qualified Primary Care Provider (1) Section 1202 of the Affordable Care Act (ACA) amended sections 1902(a)(13), 1902(jj), 1905(dd)

More information

ILLINOIS WORKERS' COMPENSATION COMMISSION MEDICAL FEE SCHEDULE INSTRUCTIONS AND GUIDELINES FOR TREATMENT ON OR AFTER 7/6/10

ILLINOIS WORKERS' COMPENSATION COMMISSION MEDICAL FEE SCHEDULE INSTRUCTIONS AND GUIDELINES FOR TREATMENT ON OR AFTER 7/6/10 ILLINOIS WORKERS' COMPENSATION COMMISSION MEDICAL FEE SCHEDULE INSTRUCTIONS AND GUIDELINES FOR TREATMENT ON OR AFTER 7/6/10 7/6/10 revisions: Changed implant reimbursement method and added accredited ambulatory

More information

2006 Provider Coding/Billing Information. www.novoseven-us.com

2006 Provider Coding/Billing Information. www.novoseven-us.com 2006 Provider Coding/Billing Information 2 3 Contents About NovoSeven...2 Coverage...4 Coding...4 Reimbursement...8 Establishing Medical Necessity and Appealing Denied Claims...10 Claims Materials...12

More information

MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS SECTION 1. GENERAL PROVISIONS

MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS SECTION 1. GENERAL PROVISIONS CHAPTER 5 MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS This chapter outlines billing procedures and reimbursement levels for health care providers who treat injured employees. It also describes

More information

100.1 - Payment for Physician Services in Teaching Settings Under the MPFS. 100.1.1 - Evaluation and Management (E/M) Services

100.1 - Payment for Physician Services in Teaching Settings Under the MPFS. 100.1.1 - Evaluation and Management (E/M) Services MEDICARE CLAIMS PROCESSING MANUAL Accessed September 25, 2005 100.1 - Payment for Physician Services in Teaching Settings Under the MPFS Payment is made for physician services furnished in teaching settings

More information

Appendix E: Modifiers that affect payment

Appendix E: Modifiers that affect payment Payment Policies Appendices Appendix E: Modifiers that affect payment Note: Only modifiers that affect payment are listed in this Appendix. Refer to current CPT and HCPCS books for a complete list of modifiers,

More information

Anesthesia Services. UnitedHealthcare Medicare Reimbursement Policy Committee

Anesthesia Services. UnitedHealthcare Medicare Reimbursement Policy Committee Anesthesia Services Policy Number ANES08272009RP Approved By UnitedHealthcare Medicare Committee Current Approval Date 08/27/2014 IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable

More information

There are two levels of modifiers: Level 1 (CPT) and Level II (CMS, also known as HCPCS).

There are two levels of modifiers: Level 1 (CPT) and Level II (CMS, also known as HCPCS). PROVIDER BILLING GUIDELINES Modifiers Modifiers are two digit or alphanumeric characters that are appended to CPT and HCPCS codes. The modifier allows the provider to indicate that a procedure was affected

More information

FAQs on Billing for Health and Behavior Services

FAQs on Billing for Health and Behavior Services FAQs on Billing for Health and Behavior Services by Government Relations Staff January 29, 2009 Practicing psychologists are eligible to bill for applicable services and receive reimbursement from Medicare

More information

KYPHON. Reimbursement Guide. Physician Reimbursement. Balloon Kyphoplasty Procedure. ICD-9-CM Diagnosis Codes. CPT Codes and Payment

KYPHON. Reimbursement Guide. Physician Reimbursement. Balloon Kyphoplasty Procedure. ICD-9-CM Diagnosis Codes. CPT Codes and Payment KYPHON Balloon Kyphoplasty Procedure Reimbursement Guide ICD-9-CM Diagnosis Codes Providers should report the ICD-9-CM diagnosis code that most accurately describes the patient s condition. Please refer

More information

HCPCS codes should be used to describe outpatient diagnostic laboratory procedures (revenue codes 300 to 319).

HCPCS codes should be used to describe outpatient diagnostic laboratory procedures (revenue codes 300 to 319). 6How Do I Bill Tribal Outpatient Hospital Services? Complete the UB-04 form for outpatient hospital services. Refer to How do I complete the UB-04? in the Billing Guidelines section for specific information

More information

Workers Compensation Medical Services Review Committee Meeting Minutes April 20, 2015

Workers Compensation Medical Services Review Committee Meeting Minutes April 20, 2015 Workers Compensation Medical Services Review Committee Meeting Minutes April 20, 2015 I. Call to order The Medical Services Review Committee was called to order at 9:00 am on Monday, April 20, 2015, in

More information

Crime Victims Compensation Program Mental Health Fees Effective January 1, 2014

Crime Victims Compensation Program Mental Health Fees Effective January 1, 2014 Copyright Information Physicians Current Procedural Terminology (CPT ) five-digit codes, descriptions, and other data only are copyright 2012 American Medical Association. All Rights Reserved. CPT is a

More information

Status Active. Reimbursement Policy Section: Anesthesia Services Policy Number: RP - Anesthesia - 001 Anesthesia Effective Date: June 1, 2015

Status Active. Reimbursement Policy Section: Anesthesia Services Policy Number: RP - Anesthesia - 001 Anesthesia Effective Date: June 1, 2015 Status Active Reimbursement Policy Section: Anesthesia Services Policy Number: RP - Anesthesia - 001 Anesthesia Effective Date: June 1, 2015 Anesthesia Policy Description: Definitions: This policy addresses

More information

Total Cost of Care and Resource Use Frequently Asked Questions (FAQ)

Total Cost of Care and Resource Use Frequently Asked Questions (FAQ) Total Cost of Care and Resource Use Frequently Asked Questions (FAQ) Contact Email: TCOCMeasurement@HealthPartners.com for questions. Contents Attribution Benchmarks Billed vs. Paid Licensing Missing Data

More information

National PPO 1000. PPO Schedule of Payments (Maryland Small Group)

National PPO 1000. PPO Schedule of Payments (Maryland Small Group) PPO Schedule of Payments (Maryland Small Group) National PPO 1000 The benefits outlined in this Schedule are in addition to the benefits offered under Coventry Health & Life Insurance Company Small Employer

More information

What s new in INCISIVE MD? Who should read these release notes?

What s new in INCISIVE MD? Who should read these release notes? April 2009 Contents What s new in INCISIVE MD? Who should read these release notes? National Correct Coding Initiative (CCI) Updates Corrected $0 Expected for Arthroscopic Chondroplasty CCI Edit Additional

More information

Coding and Payment Guide for Anesthesia Services

Coding and Payment Guide for Anesthesia Services Coding and Payment Guide for Anesthesia Services An essential coding, billing, and payment resource for anesthesiology and pain management 2006 4th edition Contents Introduction...............................

More information

Schedule of Medical Fees

Schedule of Medical Fees Kansas Workers Compensation 2014 Schedule of Medical Fees Kansas Department of Labor DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Topeka, KS 66603 K-WC 26 (Rev. 11-13) KANSAS DEPARTMENT OF LABOR

More information

Coverage and Authorization Services is available to respond to your coding questions toll-free at 800-292-2903.

Coverage and Authorization Services is available to respond to your coding questions toll-free at 800-292-2903. For Urinary Control Commonly Billed Codes October 2010 Medtronic provides this information for your convenience only. It is not intended as a recommendation regarding clinical practice. It is the responsibility

More information

eskbook Emerging Life Sciences Companies second edition Chapter 18 Medicare Reimbursement for Drugs and Devices

eskbook Emerging Life Sciences Companies second edition Chapter 18 Medicare Reimbursement for Drugs and Devices eskbook Emerging Life Sciences Companies second edition Chapter 18 Medicare Reimbursement for Drugs and Devices Chapter 18 MEDICARE REIMBURSEMENT FOR DRUGS AND DEVICES Coverage Coding There is no reimbursement

More information

Review and Approve Agenda

Review and Approve Agenda BWC Board of Directors Medical Services and Safety Committee Agenda Friday, November 19, 2010 William Green Building Level 2, Room 3 8:00 A.M. - 9:30 A.M. Call to Order Jim Harris, Committee Chair Roll

More information

Supply Policy. Approved By 1/27/2014

Supply Policy. Approved By 1/27/2014 Supply Policy Policy Number 2014R0006A Annual Approval Date 1/27/2014 Approved By National Reimbursement Forum United HealthCare Community & State Payment Policy Committee IMPORTANT NOTE ABOUT THIS You

More information

Prescription Drug Program

Prescription Drug Program Prescription Drug Program August 2011 This publication supersedes all previous pharmacy provider handbooks. Published by the Montana Department of Public Health & Human Services, July 2001. Updated October

More information

HOSPITAL OUTPATIENT BILLING AND REIMBURSEMENT GUIDE

HOSPITAL OUTPATIENT BILLING AND REIMBURSEMENT GUIDE MOUNTAIN STATE BLUE CROSS BLUE SHIELD HOSPITAL OUTPATIENT BILLING AND REIMBURSEMENT GUIDE OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS) TRADITIONAL/PPO/POS/FEP/STEEL Table of Contents Section I. Overview

More information

MEDICAL POLICY Modifier Guidelines

MEDICAL POLICY Modifier Guidelines POLICY.........PG0011 EFFECTIVE......10/30/05 LAST REVIEW... 10/13/15 MEDICAL POLICY Modifier Guidelines GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated

More information

UNITED TEACHER ASSOCIATES INSURANCE COMPANY P.O. Box 26580 Austin, Texas 78755-0580 (800) 880-8824

UNITED TEACHER ASSOCIATES INSURANCE COMPANY P.O. Box 26580 Austin, Texas 78755-0580 (800) 880-8824 UNITED TEACHER ASSOCIATES INSURANCE COMPANY P.O. Box 26580 Austin, Texas 78755-0580 (800) 880-8824 OUTLINE OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE BASIC AND EXTENDED BASIC PLANS The Commissioner of

More information

THE ASSISTANT SECRETARY OF DEFENSE

THE ASSISTANT SECRETARY OF DEFENSE THE ASSISTANT SECRETARY OF DEFENSE 1200 DEFENSE PENTAGON WASHINGTON, DC 20301-1200 HEALTH AFFAIRS MEMORANDUM FOR UNDER SECRETARY OF DEFENSE (COMPTROLLER) SUBJECT: Calendar Year 2014 Outpatient Medical,

More information

Modifier Usage Guide What Your Practice Needs to Know

Modifier Usage Guide What Your Practice Needs to Know BlueCross BlueShield of Mississippi Modifier Usage Guide What Your Practice Needs to Know Modifier 22 Usage Modifier 22 - Procedural Service The purpose of this modifier is to report services (surgical

More information

REIMBURSEMENT POLICY CMS-1500 Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction Policy 2/13/2013

REIMBURSEMENT POLICY CMS-1500 Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction Policy 2/13/2013 Policy Number REIMBURSEMENT POLICY CMS-1500 Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction Policy 2013R0121C Annual Approval Date 2/13/2013 Approved By National Reimbursement

More information

Chapter 5. Billing on the CMS 1500 Claim Form

Chapter 5. Billing on the CMS 1500 Claim Form Chapter 5 Billing on the CMS 1500 Claim Form This Page Intentionally Left Blank Fee-For-Service Provider Manual April 2012 Billing on the UB-04 Claim Form Chapter: 5 Page: 5-2 INTRODUCTION The CMS 1500

More information

Professional Fee Schedule Instruction Set For 2013

Professional Fee Schedule Instruction Set For 2013 Professional Fee Schedule Instruction Set For 2013 Table of Contents Section One: Introduction... 2 Background... 2 Conversion Factors... 2 Related Terminology... 2 Description of Columns in Montana WC

More information

NATIONAL PHYSICIAN FEE SCHEDULE RELATIVE VALUE FILE CALENDAR YEAR 2016

NATIONAL PHYSICIAN FEE SCHEDULE RELATIVE VALUE FILE CALENDAR YEAR 2016 NATIONAL PHYSICIAN FEE SCHEDULE RELATIVE VALUE FILE CALENDAR YEAR 2016 Contents: This file contains information on services covered by the Medicare Physician Fee Schedule (MPFS) in 2016. For more than

More information

Coding Systems. Understanding NDC and HCPCS. December 2014

Coding Systems. Understanding NDC and HCPCS. December 2014 Coding Systems Understanding NDC and HCPCS December 2014 White Paper Coding Systems Understanding NDC and HCPCS National Drug Code The National Drug Code (NDC) serves as a universal product identifier

More information

DC Medicaid EAPG Training

DC Medicaid EAPG Training DC Medicaid EAPG Training Provider Training 2013 Xerox Corporation. All rights reserved. Xerox and Xerox Design are trademarks of Xerox Corporation in the United States and/or other countries. Agenda Project

More information

DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS WORKERS COMPENSATION AGENCY WORKERS COMPENSATION HEALTH CARE SERVICES

DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS WORKERS COMPENSATION AGENCY WORKERS COMPENSATION HEALTH CARE SERVICES DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS WORKERS COMPENSATION AGENCY WORKERS COMPENSATION HEALTH CARE SERVICES (By authority conferred on the workers compensation agency by sections 205 and 315 of

More information

PARA Revenue Integrity Program

PARA Revenue Integrity Program The goal of the PARA Revenue Integrity Program (PRIP) is to audit and enhance each aspect of the revenue cycle process to ensure that all appropriate revenue is created, captured, coded, priced and paid

More information

Reimbursement guide. IODOSORB and IODOFLEX are Cadexomer Iodine Dressings which are available in a gel or pad format.

Reimbursement guide. IODOSORB and IODOFLEX are Cadexomer Iodine Dressings which are available in a gel or pad format. Reimbursement guide IODOSORB and IODOFLEX are Cadexomer Iodine Dressings which are available in a gel or pad format. IODOSORB and IODOFLEX remove barriers to healing and reduce pain and odor associated

More information

BILLING and ADMINISTRATIVE PROCEDURES

BILLING and ADMINISTRATIVE PROCEDURES BILLING and ADMINISTRATIVE PROCEDURES G:medcost/acc/cur/2001 Level I Curr website Rev. 1/2009-29 - Billing Information Objectives: State the basis for the Colorado Workers Compensation medical fee schedule.

More information

WORKERS COMPENSATION AGENCY DEPARTMENT OF LABOR & ECONOMIC GROWTH WORKER S COMPENSATION HEALTH CARE SERVICES

WORKERS COMPENSATION AGENCY DEPARTMENT OF LABOR & ECONOMIC GROWTH WORKER S COMPENSATION HEALTH CARE SERVICES WORKERS COMPENSATION AGENCY DEPARTMENT OF LABOR & ECONOMIC GROWTH WORKER S COMPENSATION HEALTH CARE SERVICES Filed with the Secretary of State on 2/2/2005 These rules take effect 7 days after filing with

More information

Publication CM-6 March 2013. Black Lung Medical Benefits: Questions and Answers about the Federal Black Lung Program

Publication CM-6 March 2013. Black Lung Medical Benefits: Questions and Answers about the Federal Black Lung Program Publication CM-6 March 2013 Black Lung Medical Benefits: Questions and Answers about the Federal Black Lung Program U.S. Department of Labor Office of Workers Compensation Programs Black Lung Medical Benefits:

More information

BadgerCare Plus and Wisconsin Medicaid Covered Services Comparison Chart

BadgerCare Plus and Wisconsin Medicaid Covered Services Comparison Chart and Wisconsin Covered Services Comparison Chart The covered services information in the following chart is provided as general information. Providers should refer to their service-specific publications

More information

professional billing module

professional billing module professional billing module Professional CMS-1500 Billing Module Coding Requirements...2 Evaluation and Management Services...2 Diagnosis...2 Procedures...2 Basic Rules...3 Before You Begin...3 Modifiers...3

More information

Payment of Assistant at Surgery Services in a Method II Critical Access Hospital (CAH)

Payment of Assistant at Surgery Services in a Method II Critical Access Hospital (CAH) MLN Matters Number: MM6123 Related Change Request (CR) #: 6123 Related CR Release Date: October 24, 2008 Effective Date: January 1, 2008 Related CR Transmittal #: R1620CP Implementation Date: April 6,

More information

Frequently Asked Questions (FAQs)

Frequently Asked Questions (FAQs) OVERVIEW 1. What is an ICD Code? The International Classification of Diseases (ICD) code set is used primarily to report medical diagnosis and inpatient procedures. ICD codes are mandated by the Centers

More information

Advanced Monitoring Parameters 2015 Quick Guide to Hospital Coding, Coverage and Payment

Advanced Monitoring Parameters 2015 Quick Guide to Hospital Coding, Coverage and Payment Advanced Monitoring Parameters 2015 Quick Guide to Hospital Coding, Coverage and Payment The information in this quick guide is provided by our Healthcare Economics Department, which supports Respiratory

More information

1. How do I calculate the reimbursement rate for medical services and treatment?

1. How do I calculate the reimbursement rate for medical services and treatment? MEDICAL SERVICES AND TREATMENT HOW TO CALCULATE REIMBURSEMENT RATES 1. How do I calculate the reimbursement rate for medical services and treatment? The reimbursement rate for medical services and treatment

More information