1 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 Street, NW Atlanta, Georgia http: //
2 COPYRIGHT All fee schedule amounts are copyright 2011 State of Georgia. The Current Procedural Terminology (CPT) five-digit numeric codes, descriptions, and two-digit numeric modifiers representing physician, anesthesiology, and other medical services are the 2011 edition as produced or copyright 2010 by the American Medical Association. AMERICAN MEDICAL ASSOCIATION NOTICE CPT codes, descriptions and other material only copyright 2010 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for data contained or not contained herein. STATE OF GEORGIA DISCLAIMER This document establishes professional medical fee reimbursement amounts for covered services rendered to injured employees in the state of Georgia and provides general guidelines for the appropriate coding and administration of workers medical claims. Generally, the reimbursement guidelines are in accordance with, and recommended adherence to, the commercial guidelines established by the AMA according to CPT 2011 codes. However, certain exceptions to these general rules are proscribed in this document. Providers and payors are instructed to adhere to any and all special rules that follow. PUBLISHER S NOTICE The Georgia Workers Compensation Medical Fee Schedule is designed to be an accurate and authoritative source of information about medical coding and reimbursement. Every reasonable effort has been made to verify its accuracy, and all information is believed reliable at the time of publication. Absolute accuracy, however, cannot be guaranteed. Ingenix worked closely with the Georgia State Board of Workers Compensation in the development, formatting, and production of this fee schedule. However, all decisions resulting in the final content of this schedule were made solely by the Georgia State Board of Workers Compensation. This publication is made available with the understanding that the publisher is not engaged in rendering legal and other services that require a professional license. For additional copies of this publication or other fee schedules, please call INGENIX ( ). OUR COMMITMENT TO ACCURACY Ingenix is committed to producing accurate and reliable materials. To report corrections, please visit or You can also reach customer service by calling INGENIX ( ), option 1. Questions concerning the application of the schedules of medical and hospital fees should be addressed to: Georgia State Board of Workers Compensation 270 Peachtree Street, NW Atlanta, GA Ingenix INGENIX ( )
3 Contents Section I: Background... 1 Format of the Fee Schedule... 1 Section II: Effective Date... 3 Section III: Introduction to the Fee Schedules... 5 Subsection A: Introduction to the Physician Portion of the Fee Schedule... 5 Subsection B: Introduction to the Transportation Portion of the Fee Schedule... 6 Subsection C: Introduction to the Inpatient Hospital Portion of the Fee Schedule... 6 Subsection D: Introduction to the Outpatient Surgery/ASC Portion of the Fee Schedule... 6 Section IV: General Reimbursement Requirements... 7 Considerations for Reimbursement... 7 Special Rules and Limitations... 9 Overview Section V: Evaluation and Management (E/M) Services Subsection A: Payment Ground Rules for E/M Category Subsection B: Payment Modifiers for E/M Category Section VI: Anesthesia Services Subsection A: Payment Ground Rules for Anesthesia Services Subsection B: Payment Modifiers for Anesthesia Services Section VII: Surgical Services Subsection A: Payment Ground Rules for Surgical Services Subsection B: Payment Modifiers for Surgical Services Section VIII: Diagnostic and Therapeutic Radiological Services Subsection A: Payment Ground Rules for Diagnostic and Therapeutic Radiological Services Subsection B: Payment Modifiers for Diagnostic and Therapeutic Radiological Services Section IX: Pathology and Laboratory Services Subsection A: Payment Ground Rules for Pathology and Laboratory Services Subsection B: Payment Modifiers for Pathology and Laboratory Services Section X: General Medicine Services Subsection A: Payment Ground Rules for General Medicine Services Subsection B: Payment Modifiers for General Medicine Services Section XI: Physical Medicine Services Subsection A: Payment Ground Rules for Physical Medicine Services Subsection B: Payment Modifiers for Physical Medicine Services Section XII: Home Health Services Section XIII: Transportation Subsection A: Non-Emergency Services Subsection B: Ambulance and Air Services Section XIV: Inpatient Hospital Payment Schedule Inpatient Reimbursement Methodology Implants, Durable Medical Equipment (DME), and Supplies Payment For Outliers MS-DRG Exempt Hospitals Disputed Medical Charges Section XV: Outpatient Surgery Payment Schedule Surgical Services Provided by Outpatient Hospital and Ambulatory Surgery Centers Implants, DME, and Supplies Nonsurgical Radiology Services Physical Therapy Services Modifiers Other Billing and Payment Requirements Index
5 Section I: Background The Georgia Workers Compensation Medical Fee Schedule has been prepared to establish maximum fee amounts and uniform payment guidelines for reimbursing medical providers for the treatment of injured employees subject to the authority of the Georgia State Board of Workers Compensation. This fee schedule completely replaces the previous fee schedule for medical providers services in the 2010 version of The Georgia Workers Compensation Medical Fee Schedule. All rules stated herein are pursuant to Official Code of Georgia Annotated (O.C.G.A.) 34-9 et seq. The fee schedule has been prepared in accordance with the statutes and regulations established by the State of Georgia. In accordance with such statutes and regulations, the fee amounts included herein are deemed to represent usual, customary, and reasonable reimbursement amounts for the specific services rendered. Employers, insurance carriers, self-insurers, or other payors shall use these rules for the purpose of approving and reimbursing medical charges submitted by physicians, hospitals, ambulatory surgical centers, or other medical providers for services performed in the treatment of work-related injuries or illnesses. The physician portion of the fee schedule includes fee amounts for specific medical services and procedures as identified using CPT numeric identifying codes and modifiers for reporting medical services and procedures as established by the 2011 Current Procedural Terminology (CPT), copyrighted by the American Medical Association (AMA). Any use or interpretation of CPT service descriptions not specifically described herein shall be based on CPT The transportation portion of the fee schedule includes maximum allowable rates for non-emergency transportation services. Non-emergency services are based on state-specific codes used only for workers' compensation billing purposes. Reimbursement for ambulance and air transportation is determined using the appropriate calculations for urban and rural base rate and mileage found in the Ambulance and Air Services subsection of the Transportation chapter. Ambulance and air transportation services are reported with HCPCS codes. The hospital inpatient/outpatient surgery portion of the fee schedule includes fee amounts for specific medical services and procedures as identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), volume 3, and Medicare severity diagnosis-related group (MS-DRG) numeric identifying codes. ICD-9-CM, volume 3, used for reporting the facility component of medical services and procedures, is maintained and updated by four cooperating parties: the American Hospital Association (AHA), the Centers for Medicare and Medicaid Services (CMS), the National Center for Health Statistics (NCHS), and the American Health Information Management Association (AHIMA). MS-DRGs used for reimbursement of inpatient hospital services are developed and updated annually by CMS. This fee schedule has been updated to contain the complete and most current listing of CPT descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures, MS-DRG descriptive terms and numeric identifying codes for reporting inpatient medical services and procedures, and selected ICD-9-CM, volume 3, descriptive terms and numeric identifying codes for reporting the facility component of medical services and procedures. All payors and medical providers are required to follow the general rules and requirements for reimbursement established by the AMA unless specifically instructed otherwise in this document. Current Board forms are available on the Board s website FORMAT OF THE FEE SCHEDULE This fee schedule represents the maximum amount of reimbursement providers may receive for medical or surgical services for the treatment of work-related injuries and illnesses covered under the workers compensation laws of the State of Georgia. The fee schedule document is divided into 15 sections in order to provide specific details regarding the different types of rules that determine the amount of reimbursement payable for a specific service and circumstance. Payors should note that the requirements specified in the fee CPT only 2010 American Medical Association. All Rights Reserved. 1
6 Georgia Workers Compensation Medical Fee Schedule schedule are intended to provide uniform payment policies and procedures in applying usual, customary, and reasonable payment. The following sections are included in this fee schedule: I. Background II. Effective Date III. Introduction to the Fee Schedule IV. General Reimbursement Requirements V. Evaluation and Management Services VI. Anesthesia Services VII. Surgical Services VIII. Diagnostic and Therapeutic Radiological Services IX. Pathology and Laboratory Services X. General Medicine Services XI. Physical Medicine Services XII. Home Health Services XIII. Transportation XIV. Inpatient Hospital Payment Schedule XV. Outpatient Surgery Payment Schedule Section I: Background Within each section, you will find definitions and medical terms that explain services provided. Also, in certain sections there is an index of procedures by CPT code identifiers. Use each specific section in addition to general ground rules for clarification of terms and services. The fee schedule is designed to be an accurate and authoritative source of information about medical coding and reimbursement. Every reasonable effort has been made to verify its accuracy and all information is believed reliable at the time of publication. Absolute accuracy and completeness, however, is neither intended nor guaranteed. The rules and guidelines described herein cannot specifically refer to every payment contingency; the usual, customary, and reasonable fee will govern treatment provided under unusual circumstances. The Georgia State Board of Workers Compensation reserves the authority to determine applicability of all rules of the fee schedule. Any physician, other medical professional, or other entity having questions regarding applicability to their individual reimbursement as it applies to the fee schedule, should direct any such question to the Board or to such other authority as directed by the Board. 2 CPT only 2010 American Medical Association. All Rights Reserved.
7 Section II: Effective Date These rules shall be applicable to all medical services rendered on or after the effective date of this fee schedule, which shall be April 1, Any treatment or service rendered on or after the effective date is subject to the payment methodologies and fee reimbursements described herein. CPT only 2010 American Medical Association. All Rights Reserved. 3
9 Section III: Introduction to the Fee Schedules SUBSECTION A: INTRODUCTION TO THE Physician PORTION OF THE FEE SCHEDULE The Georgia Workers Compensation Medical Fee Schedule is based upon the Resource Based Relative Value Scale (RBRVS). The reimbursable amount for each CPT numeric identifying procedure is derived from the total relative value and a conversion factor statistically determined from actual charge data in the State of Georgia. To determine the maximum allowable reimbursement (MAR) for each procedure, the unit value was multiplied by the applicable dollar conversion factor in effect on the date of payment. Providers are reimbursed the lesser of billed charges or the fee schedule amount. How to Use This Fee Schedule The maximum allowable reimbursement (MAR) for CPT codes is generally separable into eight distinct sections based on the category or type of service rendered plus a transportation fee schedule, which applies Georgia state-specific codes with MAR. Each category of service has separate instructions for the application of ground rules and modifier adjustments. The categories of service subject to this fee schedule are: General Medical Services CPT Codes Categories Evaluation & Management Anesthesia , Surgery Diagnostic & Therapeutic Radiology Pathology & Laboratory General Medicine , , , , , Physical Medicine , , , FCE01 Home Health The ground rules, modifier rules, and fee schedule reimbursement for primary or global services are included in sections V through XII of this fee schedule. As indicated, the MAR is subject to modification based on the included specific rules. See the Contents for referencing the specific subsections and page numbers. For each procedure, the fee schedule table includes the following details (if applicable): New (l), changed descriptor (s), add-on (+), modifier 51 exempt (*), moderate (conscious) sedation (K), or resequenced code (#) icons Five-digit CPT code number CPT description MAR (Maximum allowable reimbursement) Maximum reimbursement for professional component modifier 26 Maximum reimbursement for technical component modifier TC FUD (Follow-up day limits) The total MAR includes the professional component for a procedure and the technical component. Under no circumstances shall the MAR be more than the value of the technical component and the professional component combined for a procedure. For anesthesia fee amounts, the table includes basic relative values. Anesthesia fees are determined somewhat differently than other services using a relative value, physical status modifiers, qualifying circumstances, and a dollar conversion CPT only 2010 American Medical Association. All Rights Reserved. 5
10 Georgia Workers Compensation Medical Fee Schedule factor. See the Anesthesia section for an explanation of how anesthesia fee amounts are to be determined. The American Medical Association (AMA) introduced a new numbering methodology of resequencing in CPT According to the AMA, there are instances where a new code is needed within an existing grouping of codes and an unused code number is not available. In the instance where the existing codes will not be changed or have minimal changes, the AMA will assign a code that is not in numeric sequence with the related codes. The resequenced codes and descriptions are placed with their related codes out of numeric sequence in the CPT book. Resequenced CPT codes within The Georgia Workers' Compensation Medical Fee Schedule display in their numeric order and are identified with the # icon. Category II and Category III CPT codes are not recognized for The Georgia Workers Compensation Medical Fee Schedule and will not be reimbursed. SUBSECTION B: INTRODUCTION TO THE Transportation PORTION OF THE FEE SCHEDULE The Georgia Workers Compensation Medical Fee Schedule includes maximum allowable rates for non-emergency transportation services. Non-emergency services are based on state-specific codes used only for workers compensation billing purposes. Reimbursement for ambulance and air transportation is determined using the appropriate calculations for urban and rural base rate and mileage found in the Ambulance and Air Services subsection of the Transportation chapter. Ambulance and air transportation services are reported with HCPCS codes. Providers are Section III: Introduction to the Fee Schedules reimbursed the lesser of billed charges or the fee schedule amount. SUBSECTION C: INTRODUCTION TO THE Inpatient Hospital PORTION OF THE FEE SCHEDULE For inpatient hospital services, The Georgia Workers Compensation Medical Fee Schedule is based upon the CMS 2011 Medicare severity diagnosis-related group (MS-DRG) relative weights. The reimbursable amount of each MS-DRG is derived from the total relative weights and a base rate (conversion factor) statistically determined from actual charge data in the State of Georgia. To determine the MAR for each MS-DRG, the unit weight is multiplied by the applicable dollar base rate in effect on the date payment is made. The ground rules for inpatient hospital fee schedule reimbursement are included in section XIV of this fee schedule. As indicated, the MAR is subject to modification based on the included specific rules. See the Contents for referencing the specific subsections and page numbers. SUBSECTION D: INTRODUCTION TO THE Outpatient Surgery/ASC PORTION OF THE FEE SCHEDULE To determine the MAR for outpatient surgery facility services, the 2011 ICD-9-CM, volume 3, procedure codes are used in conjunction with Georgia Hospital Association information. The ground rules for outpatient surgery facility fee schedule reimbursement are included in section XV of this fee schedule. As indicated, the MAR is subject to modification based on the included specific rules. See the Contents for referencing the specific subsections and page numbers. 6 CPT only 2010 American Medical Association. All Rights Reserved.
11 Section IV: General Reimbursement Requirements This section outlines reimbursement in general. Specific guidelines by service category follow these general guidelines. The following guidelines are intended to provide rules for reimbursement of services provided in the State of Georgia under the workers compensation law for CPT codes developed by the American Medical Association (AMA) according to AMA guidelines, Medicare severity diagnosis-related groups (MS-DRG) developed by CMS, and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), volume 3, codes updated by four cooperating parties: the American Hospital Association (AHA), the Centers for Medicare and Medicaid Services (CMS), the National Center for Health Statistics (NCHS), and the American Health Information Management Association (AHIMA). Modifiers that might affect reimbursement for specific services are also located in each section. No physician, hospital, or medical provider shall bill the employee for authorized medical treatment. If an employee fails to notify a physician, hospital, or medical supplier that he/she is being treated for an injury covered by workers compensation insurance, such provider of medical services shall not be civilly liable to any person for erroneous billing for such covered treatment if the billing error is corrected by the medical provider upon notice of the same. If a provider s charge is greater than the maximum allowable rate (MAR), the provider must not bill the employee or the employer/insurer for the difference. The fees listed in the fee schedule represent all-inclusive and global fee amounts. It is important to recognize that the listing of a code number, the service or procedure, and the approved fee are not restricted to a specific specialty group. Any procedure or service and fee listed in this book may be used to designate the services rendered by any qualified physician. Such services, however, must be performed within the scope of his/her licensed practice as defined by Georgia law. The Georgia Workers Compensation Medical Fee Schedule is the reimbursement guideline for Georgia facilities and providers. (Refer to O.C.G.A (b)) Occasionally, an individual who is injured in another state will seek treatment from a medical provider in Georgia. In such a case, the injury may not be under the jurisdiction of the Georgia Act. If the injury is under the jurisdiction of another state s workers compensation act, the policy and procedures listed in this manual would not apply. CONSIDERATIONS FOR REIMBURSEMENT There are certain key principles and requirements as described in this section that may apply for determining the appropriate fee reimbursement amount under this fee schedule. These essential principles include: Medical Service Employee s Waiver of Confidentiality Authorization to Treat All-Inclusive Fees CPT Codes, Guidelines, and Icons National Correct Coding Initiative (CCI) Edits The following describes, in general, the principles and requirements that must be met for establishing applicability of this fee schedule. Authorization to Treat Preauthorization or precertification for the medical treatment or testing of an injured employee, other than as required by a certified managed care organization, is not required by Chapter 9 of Title 34 of the Official Code of Georgia Annotated (O.C.G.A.), referred to as the Workers Compensation Act, as a condition for payment of services rendered. In the event that an authorized treating physician requests preauthorization or precertification for medical treatment or testing of an employee, the procedures provided in Board Rule 205 shall be followed. For a copy of Rule 205, see the Board s website: CPT only 2010 American Medical Association. All Rights Reserved. 7
12 Georgia Workers Compensation Medical Fee Schedule The Board may require recommendations from a panel of appropriate peers of the physician, hospital, or other medical supplier in determining whether fees submitted and necessity of services rendered are reasonable. The recommendations of the panel of appropriate peers shall be evidence of the reasonableness of fees and necessity of services that the Board shall consider in its determination of appropriateness. All-Inclusive Fees The fee amounts listed in the fee schedule were determined under the principle of all-inclusive services. All-inclusive services combines certain physician services and procedures, including all necessary care, treatment, and routine supplies and services for reimbursement, into a single principal or global procedure, which reflects the overall level of services or procedures needed for the encounter. The particular services/procedures will be reimbursed using the single global fee amount established by the fee schedule. For hospital and outpatient surgery facilities, all-inclusive services combines certain facility services and procedures, including all necessary durable medical equipment (DME) and supplies for reimbursement, into a single MS-DRG for inpatient services or a single ICD-9-CM, volume 3, procedure code that reflects the overall level of services, procedures, and supplies needed for the inpatient hospital or outpatient surgery facility service. The particular services/procedures/supplies will be reimbursed using the single MS-DRG amount for inpatient services and the single ICD-9-CM amount for outpatient surgery facility services established by the fee schedule. For medical professionals billing CPT codes for surgical procedures, all-inclusive services also include all preoperative and postoperative visits listed in the follow-up days (FUD) column, plus examinations necessary for preparing the injured employee for surgery. The follow-up days refers to the time frame during which all services integral to the surgical procedure are covered by a single payment. For diagnostic laboratory testing, the primary or global fee includes both the performance of the test and the interpretation of results provided to the injured employee. No reimbursement for a separate visit would normally be allowed. There are certain exceptions to the all-inclusive services and fees provision as indicated by the explanation of separate procedures mentioned below. To the extent that other rules or guidance provided along with this fee schedule do not address every exception to this all-inclusive services and fees principle, insurers and other payors should be guided by industry standard practices regarding usual, reasonable, and customary fees. Section IV: General Reimbursement Requirements CPT Codes, Guidelines, and Icons New and Revised CPT Codes New and revised codes are identified using the same symbols found in the CPT book. CPT codes that are new for 2011 are identified with the l symbol. CPT codes with substantially changed descriptors for 2011 are identified with the s symbol. Separate Procedures Certain procedures are an inherent portion of a procedure or service and do not warrant a separate identification. If, however, such a procedure is performed independently of, and is not immediately related to, other services, it may be listed as a separate procedure. Thus, when a procedure that is ordinarily a component of a larger procedure and is performed alone for a specific purpose, it may be considered a separate procedure. Add-On Procedures The CPT book identifies procedures that are always performed in addition to the primary procedure and designates them with a + symbol. Add-on codes are never reported for stand-alone services but are reported secondarily in addition to the primary procedure. Specific language is used to identify add-on procedures such as each additional or (List separately in addition to primary procedure). The same physician that performed the primary service/procedure must perform the add-on service/procedure. Add-on codes describe additional intra-service work associated with the primary service/procedure (e.g., additional digit(s), lesions(s), neurorrhaphy(s), vertebral segment(s), tendon(s), joint(s)). Fee schedule amounts for add-on codes are not subject to reduction and should be reimbursed at the lesser of 100 percent of the listed value or the billed amount. Do not append modifier 51 to a code identified as an add-on procedure. Designated add-on codes are identified in Appendix D of the CPT book. Please reference CPT 2011 for the most current list of add-on codes. Exempt From Modifier 51 Procedures The * symbol is used to identify CPT codes that are exempt from the use of modifier 51, but have NOT been designated as CPT add-on procedures/services. As the description implies, modifier 51 exempt procedures are not subject to multiple procedure rules and as such modifier 51 does not apply. Fee schedule amounts for modifier 51 exempt codes are not subject to reduction and 8 CPT only 2010 American Medical Association. All Rights Reserved.
13 Section IV: General Reimbursement Requirements should be reimbursed at the lesser of 100 percent of the listed value or the billed amount. Modifier 51 exempt services and procedures can be found in Appendix E of CPT CPT Codes that Include Moderate (Conscious) Sedation Some CPT codes include moderate (conscious) sedation as an inherent component of the procedure. These are identified in the CPT book with a K symbol. Because these services include moderate (conscious) sedation, special rules apply when reporting the moderate (conscious) sedation CPT codes Moderate (conscious) sedation services provided by the same physician performing the diagnostic or therapeutic service that the sedation supports and requiring the presence of a second independent trained observer for monitoring purposes (CPT codes ) may not be reported in conjunction with CPT codes identified with a K symbol and listed in Appendix G of the CPT book. In rare instances, a second physician other than the physician performing the diagnostic or therapeutic service may be required to provide the moderate (conscious) sedation service (CPT codes ). When these sedation services are performed in a facility setting (e.g., hospital, outpatient hospital/ambulatory surgery center, skilled nursing facility), the second physician may report the moderate (conscious) sedation service with CPT code(s) in conjunction with CPT codes identified with a K symbol and listed in Appendix G. However, when the second physician performs the moderate (conscious) sedation services in a nonfacility setting (e.g., physician office, freestanding imaging center) CPT codes should not be reported separately and are not reimbursable when performed in conjunction with CPT codes identified with a K symbol and listed in Appendix G. See Appendix G in CPT 2011 for a list of CPT codes that includes moderate (conscious) sedation. Modifier Services A modifier is the method used by the reporting physician to indicate or flag a service or procedure code regarding special circumstances affecting that service. The service or procedure description is not affected. When applicable, the modifying circumstance should be identified by the addition of the appropriate two-digit modifier code. The two-digit modifier should be placed after the usual procedure number. If more than one modifier is used, place the Multiple Modifiers code 99 immediately after the procedure code. This indicates that one or more additional modifiers will follow. Only certain modifiers in each of the categories (Evaluation and Management, Anesthesia, Surgery, Pathology/Laboratory, Radiology, General Medicine, and Georgia Workers Compensation Medical Fee Schedule Physical Medicine) will be recognized for reimbursement purposes. The acceptable modifiers for each category will be discussed in that section of the fee schedule. National Correct Coding Initiative (CCI) Edits The CPT book provides descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. A multitude of codes is necessary because of the wide spectrum of services provided by various medical providers. Because many medical services can be rendered by different methods as well as combinations of various procedures, multiple codes describing similar services are frequently necessary to accurately reflect the service provided. While often only one procedure is performed at a patient encounter, it is also possible that multiple procedures be performed at the same encounter. In the latter case, a comprehensive code describing multiple services commonly performed together may be defined by a single CPT code. While the CPT coding system is used by providers to communicate payable services, payors must also be able to identify comprehensive codes that describe multiple procedures performed together. To accomplish this, CMS developed an edit system known as the National Correct Coding Initiative (CCI). This edit system identifies three types of services that should not be reported together. These include: Services that are a component of a more comprehensive service Services that are mutually exclusive Services that should not be reported together for other reasons The State of Georgia uses National CCI edits to identify services that are commonly performed together and that should not be billed separately when the services are provided at the same encounter. The complete list of CCI edits is too extensive to duplicate here; however, the information is available on the CMS website at SPECIAL RULES AND LIMITATIONS Specific circumstances might affect eligibility for reimbursement or the amount of reimbursement for specific services. The following listed circumstances could have an effect on eligibility or reimbursement for services. Urgent Care Facility Services performed in an urgent care facility shall be billed utilizing the most current and applicable CPT numeric CPT only 2010 American Medical Association. All Rights Reserved. 9
14 Georgia Workers Compensation Medical Fee Schedule identifying codes and modifiers. All rules and guidelines shall apply as outlined in the April 1, 2011 Georgia Workers Compensation Medical Fee Schedule. Reimbursement shall be at the rate established in the Georgia Physician Schedule. Materials Supplied by the Health Care Provider Supplies, DME, Orthotics, Prosthetics Medical supplies provided by the physician or other medical provider (e.g., sterile trays) over and above those usually included with the office visit (e.g., Band-Aids and cotton swabs) or other services rendered may be listed separately using CPT code Medical supplies and durable medical equipment are reimbursed at cost times 1.5 plus $4.00 for handling charges. Charges greater than $50.00 must be accompanied by a copy of the wholesale vendor invoice(s) showing the actual cost of the item. Certain procedures include supplies; therefore, CPT code would not be reported. Custom-made orthotics/prosthetics and rental equipment are exempt from the supplies and equipment reimbursement formula; however, usual, customary, and reasonable charges will apply. Pharmaceuticals All prescription drugs must be dispensed using an Orange Book therapeutic equivalent drug(s) (GENERIC) when available unless designated in the doctor s own handwriting on the face of the prescription, in accordance with O.C.G.A , that Brand Medically Necessary or Brand Necessary is required. Prescription drugs will be reimbursed at the current average wholesale price (AWP) as published by Medispan, plus a dispensing fee of $6.15 for generic medications and $4.11 for brand name medications. All bills submitted for reimbursement must include the National Drug Code (NDC) of the product provided unless the product provided is a repackaged unit-of-use product. All pharmaceutical bills submitted for repackaged products must include the NDC of the original manufacturer or distributor s stock package used in the repackaging process. The reimbursement allowed shall be based on the current published manufacturer s AWP price of the product as of the date of dispensing. When the authorized treating physician prescribes pharmaceuticals, the prescription will indicate by stamp or other means that it is for a workers compensation claim. Implants/Allografts/Instrumentation Certain high cost implants such as, but not limited to, bone grafts and cartilage supplied by vendor companies shall be reimbursed at cost in addition to the reimbursement at the appropriate MS-DRG or ICD-9-CM level if the wholesale vendor invoice for this item is included with the facility bill. This additional charge above the MAR, taking into account Section IV: General Reimbursement Requirements reasonable cost, medical necessity, and appropriateness, shall be negotiated in advance with the payor. Instrumentation inserted in surgical procedures is to be reimbursed to the provider at cost when the wholesale vendor invoice is included in the facility bill. Physician Extenders (PE) Clinical Nurse Specialist (CNS), Nurse Practitioner (NP), or Physician Assistant (PA) The clinical nurse specialist (CNS), nurse practitioner (NP), or physician assistant (PA), if qualified by training and experience as determined by the supervising physician, may perform medical treatments, diagnostic procedures, or other delegated duties and tasks which are allowable by law, approved by the state licensing board, and which fall within the normal scope of practice of the supervising physician. For scheduled visits, the Board requires a physician to provide evaluation and treatment in the course of the first visit. In situations of major/minor emergency, urgent care injuries, or other medical conditions requiring immediate attention, and where that care is provided in a medical facility staffed by physician extenders (PE) under the direction and supervision of a physician, services by the physician extender are covered for the initial treatment and visit. If follow-up treatment is necessary, the patient must then be referred to a physician for follow-up visit, treatment, and/or evaluation. Medical facilities covered include occupational medical centers, hospital emergency rooms, hospital-based clinics, rural health clinics, or federally qualified health centers. The federal tax ID number for the supervising physician is to be used on claims for services rendered by a PE. Subsequent visits to a PE who is under the general supervision of the physician shall be paid in accordance with the Board fee schedule. When professional services are directly performed by a CNS, NP, or PA, the reimbursement shall be at 85 percent of the fee schedule MAR or the provider s charge, whichever is less. If the CNS, NP, or PA renders the service under the general supervision of a physician and incident to rules apply as specified in the Medicare Benefit Policy Manual, Pub , chapter 15, secs. 60.1, 60.2, 60.3, the applicable reimbursement shall be at 100 percent of the fee schedule or the provider s charge, whichever is less. While the supervising physician is responsible for the overall direction and management of the professional activities of the CNS, NP, or PA, the supervising physician is not required to physically be on site at the time of service. However, if the supervising physician is not physically present with the CNS, NP, or PA, he or she must be immediately available to the CNS, NP, or PA for consultation purposes by telephone or other effective, reliable means of communication. See the Medicare Benefit Policy Manual, Pub. 10 CPT only 2010 American Medical Association. All Rights Reserved.
15 Section IV: General Reimbursement Requirements 100-2, chapter 15, section 190(C) for Medicare requirements for PA supervision, section 200(D) for NP collaboration/supervision, and section 210(D) for CNS collaboration/supervision. It is the responsibility of the supervising physician to ensure compliance with all ethical and licensing standards and to co-sign all medical notes. Append the appropriate CPT procedure with modifier PE. Physicians may not bill for oversight of these services in addition to an office visit. Reimbursement of PA, NP, or registered nurse first assistant (RNFA) as a surgical assistant shall be at 10 percent of the MAR for the CPT code or the practitioner s usual and customary charge, whichever is less, for those procedures that are exempt from the Medicare 5 percent rule. If Medicare records indicate that a first assistant is used less than 5 percent of the time nationwide for a particular surgical procedure, then the procedure is added to the restricted 5 percent list. (See the Medicare Claims Processing Manual, Pub , chapter 12, section ) CPT codes that have assistant at surgery restrictions are updated each year and can be found in the current Medicare National Physician Fee Schedule Relative Value File. The column Surg Asst in the above referenced file provides a numeric code (0, 1, 2, or 9) that identifies any restrictions related to assistant at surgery services. The restrictions related to these numeric codes are as follows: Surgical Assistant Ind Payment Restriction 0 Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. 1 Statutory payment restriction for assistants at surgery applies to this procedure. Assistant at surgery may not be paid. 2 Payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid. 9 Concept does not apply. If circumstances warrant the concurrent services of a surgeon and one of the types of assistants as listed herein and it is medically necessary, those services may be performed by a physician extender (PE) in the place of an assistant surgeon when medically appropriate. In accord with O.C.G.A , the RNFA shall not be on the staff of a hospital or the treating physician. Append the appropriate CPT procedure with modifier AS. When an office is billing for both the primary surgeon and the surgical assistant, two lines are used on the CMS-1500 or a Uniform Billing 04 (UB-04). Georgia Workers Compensation Medical Fee Schedule Interpretation In circumstances where an interpreter is required during face-to-face evaluation and management services, or physical medicine evaluations ( ), provided to the injured worker by a physician or PE, whether interpretation is provided live, via telephone or video, add state-specific modifier TR to the E/M code. Reimbursement will be an additional 25 percent of the lesser of billed charges or maximum allowable rate of that code only. Prolonged service codes may not be used in combination with this modifier. Additional reimbursement as outlined above does not apply to independent medical evaluations (IME). In circumstances where an interpreter is required for an injured worker, and the service is provided by telephone with a physician or qualified non-physician health care provider, use the appropriate CPT codes (physicians) and (qualified non-physician health care providers), and append state-specific modifier TR. These codes should be used in accordance with the guidelines and descriptions found in CPT Reimbursement will be an additional 25 percent of the lesser of billed charges or maximum allowable rate of that code only. Physical Therapists/Occupational Therapists Services performed by a physical therapist and/or occupational therapist shall be under the direction of the authorized treating physician detailing the type, frequency, and duration of therapy to be provided. Physical therapists and/or occupational therapists cannot be reimbursed for office visits. See Physical Medicine for a full discussion of these services. Physical Medicine Maximum Per Visit and/or Day No more than four charges will be reimbursed per visit/day regardless of medical necessity. No more than two of the charges can be modality codes (CPT codes ). Each unit (15-minutes) reported counts as one charge. Exemptions to this rule are as follows: 1. An injured worker has been diagnosed with a catastrophic injury O.C.G.A (g). 2. CPT codes and report work hardening/work conditioning. CPT code reports the first two hours and CPT code reports each additional hour. The total dollar amount reimbursed for work hardening/work conditioning reported with these two CPT codes shall not exceed $ per visit/day. 3. State-specific code FCE01 must be used for billing functional capacity evaluation. The maximum allowable rate of reimbursement is $45.41 per 15 minutes (not to exceed $600.00). CPT only 2010 American Medical Association. All Rights Reserved. 11
16 Georgia Workers Compensation Medical Fee Schedule Section IV: General Reimbursement Requirements 4. CPT code must be used by physical/occupational therapists when billing for Physical Performance Test/Measurements that are required by the treating physician in preparing an impairment rating. No more than 4 time units per visit per day can be billed. An additional physical medicine treatment can be conducted on the same day, with reimbursement in accordance with Section XI Physical Medicine Services. Modifier 59 may be used when multiple procedures are performed on the same day. 5. CPT code should be used by the treating physician when performing an impairment rating. 6. Under the guidelines above, Physical Performance Test/Measurement testing and functional capacity evaluation can be performed on the same day by physical/occupational therapists. Modifier 59 may be used when multiple procedures are performed on the same day. 7. Reporting CPT code Orthotic management and training (including assessment and fitting when not otherwise reported), for custom-made orthotics, CPT code Prosthetic training, and CPT code Checkout for orthotic/prosthetic use, established patient. 8. By mutual agreement of all parties. Independent Medical Exam (IME) Employers/insurers have the right to request that the injured employee submit to an independent medical examination (IME), performed by a duly qualified physician or surgeon designated and paid by the employer/insurer. The employer/insurer must notify the employee in writing at least 10 days in advance of the time and place of the examination. Advance payment of travel expenses must accompany the notice. Travel beyond the employee s home city shall include the actual cost of meals (up to $30.00 per day) and lodging. When travel is by private vehicle, the rate of mileage shall be according to Board Rule 203(e). The employee shall have the right to have present at such examination any duly qualified physician or surgeon, provided and paid for by the employee. The employee, after an accepted compensable injury and within 120 days of receipt of any income benefits, shall have the right to one IME performed at a reasonable time and place, within this state or within 50 miles of the employee s residence, by a duly qualified physician or surgeon designated by the employee and paid for by the employer/insurer. The employer or insurer shall be notified in writing in advance. Such examination shall not repeat any diagnostic procedures which have been performed since the date of the employee s injury unless the costs of such diagnostic procedures in excess of $ are paid for by a party other than the employer or insurer. Payment for independent medical examinations will be based on time spent in the review of medical records, test reports, a physical examination, and a written report regarding the medical condition of the injured employee. Time will be the essential factor in determining the reimbursement amount for an IME. The provider shall complete Board Form WC-20 (a) Medical Report or the CMS-1500 form. Use state-specific code IME01 when reporting an independent medical exam (IME). The following hourly rate will establish the maximum allowable reimbursement for this service. Time Rate $ first hour or parts thereof $ each additional 15 minutes For a no-show at an independent medical examination, reimbursement shall be at $ Impairment Evaluation The basis to determine permanent impairment should be the Guide to the Evaluation of Permanent Impairment, Fifth Edition, published by the American Medical Association. Permanent partial impairment (PPI) applies to any measurable, objective loss of function of some part of the body after the stage of maximum medical improvement (MMI) has been reached and the condition is stationary. The authorized treating physician shall complete Board Form WC-20 (a) Medical Report or the CMS-1500 form and submit the form to the employer/insurer when a permanent partial disability rating is determined. If a physical examination is necessary, evaluation and management CPT code must be used in billing an impairment rating, and no other evaluation and management CPT code can be used along with CPT code when billing for impairment ratings performed by the authorized treating physician. Work Hardening/Work Conditioning The CPT codes and can only be used by physician referral and when treatment is initiated and directly supervised by the physician, chiropractor, licensed physical therapist, or licensed occupational therapist. Unlisted Service or Procedure and New CPT Codes A service or procedure may be provided that is not listed in this schedule. When reporting such a service, the appropriate unlisted procedure code may be used to indicate the service. When reviewing charges for unlisted medical professional services or procedures, payors should apply usual, customary, and reasonable charges. When reporting unlisted procedure MS-DRG or ICD-9-CM procedure codes, 12 CPT only 2010 American Medical Association. All Rights Reserved.
17 Section IV: General Reimbursement Requirements reimbursement is at percent of charges. In compliance with O.C.G.A (a), these usual, customary, and reasonable charges shall be limited to such charges as prevail in the State of Georgia for similar treatment. Annually on January 1 of each calendar year, the American Medical Association (AMA) releases updates to CPT codes, with new CPT codes added, CPT codes deleted, and CPT codes revised. The Georgia Workers Compensation Medical Fee Schedule may not have the AMA s most current updated information until after January 1. In this case, a maximum allowable reimbursement rate will not be assigned. New codes without an assigned fee should be considered to fall under the BR or by report maximum allowable reimbursement until the next fee schedule update. By Report If a procedure is not among those listed in the fee schedule, a reasonable fee must be charged, and may require a special report. A service that is infrequently provided, unusual, varies from other described procedures, or a new technique, methodology, or code may require a special report in determining the medical appropriateness of the service. Pertinent information should include: Adequate definition and description of procedure or service as performed is required Nature, extent, and need (diagnosis and rationale) for the service or procedure Time and effort required to perform the service or procedure Skill level necessary for performance of service or procedure Equipment use (if applicable) Other information as needed Additional items that may be included are: Complexity of symptoms Final diagnosis Pertinent physical findings (such as size, location(s), and number of lesion(s), if appropriate) Diagnostic and therapeutic procedures (including major and supplementary surgical procedures if appropriate) Concurrent problems Follow-up care Payment will be determined based upon usual, customary, and reasonable charges. Georgia Workers Compensation Medical Fee Schedule Medical Expense Disputes Employers/insurers may conform charges according to the fee schedule adopted by the Board, and the charges listed in the fee schedule shall be presumed usual, customary, and reasonable and shall be paid within 30 days from the date of receipt of charges. Employers/insurers shall not unilaterally change any CPT, MS-DRG, or ICD-9-CM code of the provider. All automatically conformed charges according to the fee schedule shall be for the CPT code listed by the provider. In situations where charges have been reduced or payment of a bill denied, the carrier, self-insured employer, or third-party administrator shall provide an explanation of benefits (EOB) with payment information explaining why the charge has been reduced or disallowed, along with a narrative explanation of each EOB code used. In all claims, any health service provider whose fee is reduced to conform to the fee schedule and who disputes that fee, or any employer/insurer who disputes the CPT code used by the provider for services rendered shall, in the first instance, request peer review of the charges, and may thereafter request a mediation conference by filing Form WC-14 with the Board. For charges not contained in the fee schedule and which are disputed within 30 days as not being usual, customary, and reasonable, the aggrieved party shall follow these procedures: 1. An employer or insurer shall pay when due all charges deemed reasonable, and follow the procedures set forth in subsection (2) for review of only those specified charges that are disputed. 2. For charges not contained in the fee schedule and which are disputed as not being the usual, customary, and reasonable charges prevailing in the State of Georgia, the employer, insurer, or physician shall file a request for peer review with a peer review organization authorized by the Board within 30 days of the receipt of charges by the employer/insurer, and shall serve a copy of the request and supporting documentation upon all parties and counsel. 3. The peer review committees approved by the Board are listed below. These committees may be contacted at the following addresses and telephone numbers: Mr. Michael Walsh, CAE, Executive Director Georgia Chiropractic Association, Inc Northlake Parkway, Suite 201 Tucker, GA (770) ; FAX (770) Mr. Clark Thomas, MPA, CAE, Executive Director Georgia Psychological Association 2200 Century Parkway, NE, Suite 660 Atlanta, GA (404) ; FAX (404) CPT only 2010 American Medical Association. All Rights Reserved. 13
18 Georgia Workers Compensation Medical Fee Schedule Section IV: General Reimbursement Requirements Mr. Stuart Platt, M.S.P.T., P.T., Principal Appropriate Utilization Group, LLC 881 Piedmont Avenue Atlanta, GA (404) If there is no appropriate peer review committee, the party requesting review may request a mediation conference by filing Form WC-14 with the Board. The charges submitted, which conform to the fee schedule adopted by the Board, shall be prima facie proof of the usual, customary, and reasonable charges for the medical services provided. 5. The employer/insurer shall, within 30 days from the date that a decision regarding the peer review of charges or treatment is issued by a peer review organization, make payment of disputed charges based upon the recommendations, or request a mediation conference. The peer review committee shall serve a copy of its decision upon the employee, if unrepresented, or the employee s attorney. A physician whose fee has been reduced by the peer review committee shall have 30 days from the date that the recommendation is mailed to request a hearing. In case of a mediation conference, the recommendations of the peer review committee shall be evidence of the usual, customary, and reasonable charges. 6. In cases where the peer review committee recommends that the fee be reduced, the employer/insurer shall pay the physician the fee amount recommended by the peer review committee less the filing costs initially paid by the employer/insurer. In the event the peer review committee recommends the entire fee be disallowed, the employer/insurer may automatically deduct the filing costs for the peer review from future allowable expenses submitted by the physician for treatment or services rendered to the employee arising out of the same injury. (Refer to O.C.G.A ) Appointed Physician (Refer to O.C.G.A and Board Rule 205.) The Board or an Administrative Law Judge may, upon application of either party or upon their own motion, appoint one or more disinterested and duly qualified physicians or surgeons to perform any necessary medical examination of an employee, and to report or testify with respect thereto. The physician or surgeon shall be allowed travel expenses and a reasonable fee, to be paid by either or both parties, as directed by the Board, any Board member, or an Administrative Law Judge. Physician Testimony/Deposition Physicians and surgeons may be called upon or may be issued a subpoena, which is a legal instrument of the court requiring any citizen to appear in court as a witness at a specified time, to testify as an expert witness before the Workers Compensation Board. The expert witness is legally bound to declare his/her knowledge of the case and express medical opinions according to the rules of the court. Hearings are conducted in an informal manner. Witnesses are sworn and their testimony is recorded. Generally, the parties to the claim offer medical testimony related to the extent of the injury and whether the injured employee is physically able to return to his/her former job duties or is able to accept other more limited employment. In most instances, testimony of physicians is obtained through deposition. The deposition generally serves to relieve the physician of the necessity of going to court. Physicians and surgeons shall be given two weeks prior notice to giving medical testimony and such testimony shall be scheduled at a mutually agreeable time and place. Charges for medical testimony should be reported using CPT code and paid within 30 days from receipt of billing. Payment for a deposition will be based on actual time spent reviewing medical records before giving medical testimony and actual time spent testifying. The following hourly rate will establish the maximum allowable reimbursement for this service: Time Rate $ first hour or parts thereof $ each additional 15 minutes Special Reports Special reports such as insurance forms that convey more than the information conveyed in usual medical communication or standard reporting forms should be reported with CPT code Special reports meeting the above requirements will be reimbursed at a MAR of $ Malpractice Liability The employer/insurer shall not be liable in damages for malpractice by a physician or surgeon furnished pursuant to the workers compensation law, but the consequences of any malpractice shall be deemed part of the injury resulting from the accident and the employee shall be compensated for such injury. Medical Records The medical provider s medical record is the basis for determining medical necessity and for substantiating the service(s) rendered; therefore, the medical record must be legible and should include the following: office notes and/or surgical notes, progress notes, operative notes, diagnostic test results, and any other information necessary to support 14 CPT only 2010 American Medical Association. All Rights Reserved.
19 Section IV: General Reimbursement Requirements the services rendered. All bills must be submitted using CPT, ICD-9-CM, or MS-DRG codes either on Board Form WC-20(a), CMS-1500, or a Uniform Billing 04 (UB-04). These forms must be properly filled out, with attached documentation, at no charge to the party responsible for payment. Failure to submit supporting documentation and forms required by the Board might jeopardize or delay payment. Medical providers are only required to submit the complete set of documentation once. If documentation is incomplete, the medical provider is required to submit the missing information. After the complete documentation has been submitted to the payor once, the medical provider can charge for additional copies in accordance with costs defined below. Services provided pursuant to the Workers Compensation Act are not confidential from the employer/insurer that, by law, is responsible for payment of medical services. Generally, costs for these copies will be charged against the party responsible for payment of medical expenses. (Refer to Board Rule 200(f)(1)(2)(3)) Medical records copy charges under a workers compensation claim shall be billed at thirty dollars ($30), sales tax (if applicable), and actual cost for postage to mail the documents per request. This fee shall cover any request of up to 150 copied pages, and includes any costs associated with research, retrieval, and certification of the records or information requests. Any request that is for more than 150 copied pages shall be billed at twenty cents ($0.20) per page, or image if on CD or other electronic storage device that allows electronic retrieval, or copies made from microfilm, and shall include any costs associated with research, retrieval, and certification of the records or information requested. No additional fee beyond the twenty-cent ($0.20) per-page charge shall be billed for requests over 150 pages other than actual cost for postage to mail the documents per request and sales tax (if applicable). Example 1: 50-page document $0.20 x 50 pages = $10.00 Total Charges: $30.00 plus actual cost for postage and sales tax, if applicable Example 2: 175-page document $0.20 x 175 pages = $35.00 Total Charges: $35.00 plus actual cost for postage and sales tax, if applicable Georgia Workers Compensation Medical Fee Schedule Providers who use a medical records company to make and provide copies of medical records must ensure that reimbursement requirements are followed in accordance to the above fee schedule guidelines. X-ray copy charges will be billed at $9.50 per copy. Late Payment All reasonable medical, surgical, hospital, pharmacy goods and services shall be payable by the employer or its workers compensation insurer within 30 days of receipt of such charges and reports required by the Board. In the event that any documents or other information needed to process the claim or any portion thereof have not been provided to the employer or insurer, an explanation of benefits with payment information indicating why the charge has been reduced or disallowed shall be provided by the employer/insurer within 30 days of receipt of such charges. If any charges for health care goods or services, for which all Board-required information is provided, are not paid within the 30-day period, penalties shall be added to such charges and paid at the same time as and in addition to the charges claimed for such services. Refer to O.C.G.A and Board Rule 203 for complete rules and regulations. Broken or Missed Appointments No fees shall be allowed for broken or missed office visits, with the exception of independent medical examination (see IME this section). Notify the employer/insurer if the injured employee is not following the prescribed course of treatment. OVERVIEW The preceding guidelines outline reimbursement in general. Specific rules regarding reimbursement for services rendered by specific category should supplement the general guidelines (i.e., Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, General Medicine, and Physical Medicine). These specific guidelines are in addition to rules established for the usage of CPT codes by the American Medical Association (AMA), Medicare severity diagnosis-related groups (MS-DRG) developed by CMS, and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), volume 3, codes updated by four cooperating parties: the American Hospital Association (AHA), the Centers for Medicare and Medicaid Services (CMS), the National Center for Health Statistics (NCHS), and the American Health Information Management Association (AHIMA). The following sections will describe payment in general terms by the category of service provided. CPT only 2010 American Medical Association. All Rights Reserved. 15
20 Georgia Workers Compensation Medical Fee Schedule Sections V through XII of the fee schedule provide specific payment ground rules separately for each of the eight medical professional service categories, section XIII provides specific ground rules for transportation, and sections XIV through XV provide specific payment ground rules for hospital inpatient/outpatient surgery services. Explanation of the modifiers and the maximum allowable reimbursement is included in each of these sections of the fee schedule. Section IV: General Reimbursement Requirements The payment ground rules are provided in 11 separate fee subsections. The ground rules encompass the 10 distinct medical and hospital inpatient/outpatient surgery service categories and transportation. The rules for one service category may include certain principles that apply equally to another service category. Similarly, the ground rules applicable to one category of service apply equally to all professional providers regardless of provider specialty. 16 CPT only 2010 American Medical Association. All Rights Reserved.