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.