Table of Contents. Overview of StreetSelect Program Objectives... 5 Medical Director... 6 Medical Advisory Board... 6 Role and Function...

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2 Table of Contents Overview of StreetSelect... 4 Program Objectives... 5 Medical Director... 6 Medical Advisory Board... 6 Role and Function... 7 Provider Expectations... 8 Initial Reporting of Injury... 9 StreetSelect Case Management... 9 Medical Provider Procedures Credentialing Alternate Credentialing Options Provider Responsibility Provider Reconsideration or Reinstatement Demographic Changes Recovering Worker Identification Card and Letter of Compensability Network Containment and Referral Opting Out of StreetSelect Billing Essentials and Coding Prior Authorization Workers Compensation Rule Disposable/Non Reusable Supplies Health Insurance Portability and Accountability Act (HIPAA) Request for Additional Information Adjustment of Denied/Paid Invoices Coding Conventions CPT 4 Codes (HCPCS Level I) HCPCS Level II National Alpha numeric Codes HCPCS Level III Local Codes ICD 9 CM Diagnosis Codes Resource Based Relative Value Scale (RBRVS) Methodology Conversion Factors Comprehensive/Component Services (Rebundling) Global Surgery Package MODIFIERS DME Modifiers (Per HCPCS Level II) Practice Expense By Report Services/Unlisted Procedures Injections Anesthesia

3 Pathology and Laboratory Services Surgery Services Ambulatory Surgical Center Provider NPI Requirement Official Disability Guidelines (ODG) Provider Remedial Action Medical Necessity Review Utilization Review Informal Resolution Grievance Policy and Procedures Definitions: General procedures: Written Grievance Exemptions: Confidentiality APPENDIX A... 1 APPENDIX B... 2 APPENDIX C

4 Overview of StreetSelect In 2003, the West Virginia Legislature passed an extensive workers compensation reform bill, SB One of the most important components of this vital legislation supports the development of managed care and preferred provider organization networks. Through these networks, employers can require their employees to seek workers compensation covered services from providers who contract with a managed care or preferred provider organization network. This provision has broad and significant benefit for all stakeholders of the workers compensation system, employees, employers, and providers. BrickStreet Insurance, West Virginia s largest private carrier that provides workers compensation, has responded to this opportunity by partnering with Acordia CompNet s Preferred Provider Organization CompNet and creating StreetSelect. StreetSelect is a selected network, choosing physicians and other providers whose history provides an indication of their commitment to our mutual goal of returning injured employees to work as soon as practical, using efficient, quality practices and care. StreetSelect offers a broad array of providers to assure reasonable access and choice for the injured workers. StreetSelect s network of physicians and other providers is offered to all West Virginia employers with BrickStreet Insurance workers compensation coverage. The StreetSelect network of medical providers compliments BrickStreet utilization review, case management, medical bill review and quality assurance programs. These initiatives, including uniform standards for treatment and duration of recovery and return to work goals, are a continuous process. They are designed to evaluate the adequacy and appropriateness of health and administrative services and pursue opportunities to help improve health and rehabilitation outcomes, thereby enhancing provider satisfaction with StreetSelect. Continued provider participation with StreetSelect is based upon adherence to the standards. StreetSelect will continually strive for and maintain quality and efficiency in all aspects of its operation. Accordingly, several key operating principles have been established. These include: Proactive provider/employer relations and education Ongoing network access management ensuring adequate choice for employees Data analysis and outcome measurement Professional oversight and support of the network by a Medical Advisory Board Ongoing assessment of provider performance Network coordination with claims adjusters and claims management functions

5 Program Objectives Medical providers form the service component of StreetSelect. Their effectiveness is greatly influenced by the referral, treatment, and communication environment in which they practice. StreetSelect is designed to address many of the past concerns experienced by providers treating workers compensation patients. Thus, their ability to produce quality outcomes is enhanced. This is accomplished by prompt decisions involving authorizations and payments, peer consultation with the StreetSelect Medical Director, Medical Advisory Board, and StreetSelect medical staff responsive communications overall. StreetSelect has three basic objectives: 1. To provide appropriate, high quality and timely health care to recovering workers. 2. To expedite the workers return to employment by avoiding unnecessary delays. 3. To minimize disability. To achieve these objectives, StreetSelect recognizes the importance of recruiting and maintaining a network of providers from specialty areas that are involved in treating occupational injuries and illnesses. StreetSelect features important to providers include the following: StreetSelect affords the opportunity to develop positive and proactive relationships with employers that participate in StreetSelect s preferred provider organization network. StreetSelect facilitates these relationships by encouraging and sponsoring joint training opportunities, work site tours, and ongoing dialog among key representatives of employer and provider entities. StreetSelect network participants are paid for their services in an expedient manner, while providing them incentive to continue their participation and to follow StreetSelect program guidelines. StreetSelect utilizes treatment protocols that provide a framework for the treating physician. These protocols define their expectations regarding treatment parameters and duration estimates. They also lend consistency and structure to the treatment of work related injuries

6 Medical Director StreetSelect has appointed licensed physician, Dr. Randall Short who is responsible for the clinical aspects of StreetSelect s quality management and utilization review programs. Dr Short will communicate with network providers on quality management issues or other concerns. These responsibilities include: Contributing to policy and operational manuals and instructions Providing written and/or telephonic communications regarding individual situations. Serving on Medical Advisory Board Reviewing selected independent medical evaluation reports for accuracy and appropriateness Providing Quality Assurance/Management oversight Being Liaison between provider community and StreetSelect Providing education and in service training for network providers Present to stakeholders The Medical Director staffs the Medical Advisory Board as necessary to assist in establishing and implementing quality management activities. Medical Advisory Board The Advisory Board includes licensed physician Dr. Randall Short of BrickStreet. Other Medical Advisory Board members are appointed representing specialties in the network including: Psychiatry Orthopedic Surgery Medical Rehabilitation Pain Management Chiropractic

7 Vocational Rehabilitation Occupational Medicine Emergency Medicine Physical Therapy General Surgery and Disability Management Family Practice Additions per recruitment and recommendations of the Medical Advisory Board Role and Function The Medical Advisory Board carries out a variety of functions including: Overseeing and supporting network physicians Verifying and interpreting treatment standards Reviewing physician credentials Assisting in addressing physician quality Participating in the quality management process Assisting in determining if physicians meet selection criteria Assisting in determining if physicians meet standards of care Assisting in making utilization management and addressing patient safety Reviewing and approving credentialing policies and procedures annually Participate in dispute resolution and grievance process

8 Provider Expectations StreetSelect requires a high level of commitment and cooperation from each contracted provider. Comply with treatment and duration guidelines; adhere to communication processes adopted by StreetSelect. Make their best effort to perform the initial evaluation and treatment within two business days of initial telephone contact from the injured worker or employer. Refer injured workers only to in network providers, specialists and facilities as necessary. Prior approval must be obtained for out of network services with the exception of emergency treatment. Perform medical treatment subject to review by and subsequent approval of BrickStreet claim adjusters, nurse reviewers and Medical Directors. Make their best effort to communicate appointment results and follow up plans to the claims administrator within 24 hours of office visit. Promptly communicate out of the ordinary information about the injured worker to BrickStreet. When a provider of medical services or treatment makes referrals for medical services or treatment to a provider or entity in which the provider making the referral has an investment interest, the referring provider shall disclose that investment interest to the employee, the insurance commissioner, the employer and BrickStreet, within thirty (30) days from the date the referral was made. The treating physician should assist the injured worker in return to work options early on, even a few hours per day will keep the claimant active and productive and recovery time may be reduced. Most employers are willing to accommodate work related injuries by providing temporary transitional duty. Cooperate with Nurse Case Managers and Return to Work Specialist s to facilitate a prompt, safe return to work. This may involve completing the Physician s Response to Physical Capabilities form located at the end of this manual or at

9 Initial Reporting of Injury It is the medical provider s responsibility to ascertain whether he or she is the first attending practitioner. If so, the medical provider will take the following action: Give emergency treatment. Immediately complete and forward Section II of the Employee s and Physician s Report of Injury (BI 1) to the employer s workers compensation administrator. Instruct and give assistance to the injured worker in completing his or her portion of Section I of the Employee s and Physician s Report of Injury. The Initial Report of Injury must be forwarded to the employer and a copy kept by the claimant. It shall include a narrative report containing the following information so there is no delay in adjudication of the claim or payment of compensation. Complete history of the industrial accident or exposure. Comprehensive description of physical findings and prognosis. Specific diagnosis with ICD 9 CM code(s) and narrative definition relating to the injury. Type of treatment rendered. Known medical, emotion, or social conditions which may influence recovery or cause complications. Estimated time loss due to the injury. StreetSelect Case Management Case management serves as a means for achieving wellness and autonomy through advocacy, communication, education, identification of service resources, and service facilitation. The claim adjuster helps identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost effective manner in order to obtain optimum value. Its underlying premise is that when an individual reaches the best possible level of wellness and functional capability, everyone benefits: the injured workers, their support systems, the employer, the health care delivery systems, and the reimbursement sources. In regards to case management as well as vocational rehabilitation network resources, StreetSelect believes services are best offered in a climate that allows direct communication among the claim adjuster, nurse case manager, internal and external Return to Work Specialists, the medical provider, the injured worker, the employer, and appropriate service personnel in order to optimize the outcome for all concerned. Cooperation through a team approach based on sound principles of practice promotes success

10 Claims management and medical billing processes are coordinated with BrickStreet to expedite and conform to StreetSelect commitments to network providers. Claims and medical billing staff communicate closely with StreetSelect regarding individual claims and/or individual employee information. This allows StreetSelect to promptly respond with timely solutions to any issues that may arise. Special Code for Reimbursement The local code AES0l has been designated to reimburse our PPO providers for administrative services. This code is billable at $55 and may be submitted one time per month for a period of six (6) months. Reimbursement for this code applies if the claimant is receiving temporary total benefits or if the claimant has returned to modified duty or a transitional position. AES01 may be submitted only by the StreetSelect treating physician of record and may not be utilized by the consulting physicians or specialists that do not assume continuing care and treatment Our goal is to help establish a culture that promotes interaction and enhances communication among the BrickStreet Team. If you have any questions, please contact our Customer Service Department at BRICK. Medical Provider Procedures The following procedures must be followed by all network providers: Credentialing StreetSelect references providers who are credentialed and enrolled in SelectNET Plus (SNP). Those providers that are not members of SNP will be considered for network participation based on credential verification of their workers compensation status. SNP has a working relationship with several Physician Hospital Organizations (PHOs) that credential the individual practitioners they represent to NCQA or URAC standards. These PHOs report information about the practitioners they represent when each practitioner completes the PHO specific credentialing and contracting process. StreetSelect may also accept provider credentialing through a PHO or hospital. The PHO and hospital agree to notify StreetSelect, in writing, if a provider is no longer credentialed. Alternate Credentialing Options A practitioner who is credentialed by a PHO utilized by SNP may elect not to participate with SNP, but desire to participate in StreetSelect. In this circumstance, the practitioner will be considered as meeting the credentialing requirements upon verification by the PHO. If a provider is not credentialed by SNP but has privileges at a hospital or facility that is accredited, StreetSelect will accept the credentialing of the facility if the facility agrees to accept this responsibility and notify StreetSelect, in writing, of any change in the status of the provider

11 Provider Responsibility It is the responsibility of the provider to notify BrickStreet, in writing, of any loss or other change in a physician s license, registration, certification, credential status, or other authorization to practice in any state. Provider Reconsideration or Reinstatement A provider dismissed by StreetSelect will have the opportunity to reapply after a period of six months. To do so, the provider must submit a written request detailing a commitment to comply with specific StreetSelect guidelines and procedural requirements. Decisions regarding network membership will be made in accordance with network needs as well as compliance with performance standards. The Medical Advisory Board will review all requests for reinstatement and make a recommendation. Providers terminated after investigation of a reason contrary to the best interests of StreetSelect, its members, or injured workers will not be considered for reinstatement. Demographic Changes All StreetSelect providers must keep StreetSelect informed of any demographic changes such as: Name change of Group or Physician Change in credentialing status Change of Address E Mail Address New telephone or facsimile number Additional office location Provider leaves/joins a practice New ownership of practice New Tax Identification Number (with effective date and copy of the W 9 form) Change in hospital affiliation Change in license such as losing license or suspension Change in liability coverage Change in practice limitations

12 Adding a provider to a group contract Any other pertinent information Recovering Worker Identification Card and Letter of Compensability The injured worker will receive a letter of compensability and an identification card, The identification card is not to be construed as authorization for medical services or payment (see employee identification card in Appendix A). Network Containment and Referral StreetSelect complies with the worker s right to seek care from non network providers at his or her own expense. It is understood that all benefits related to services provided by a non network provider may be affected. The worker s medical expenses or indemnity benefits may not be covered if they choose a medical provider who is not listed in the StreetSelect directory; unless they meet the conditions listed below. Opting Out of StreetSelect Injured workers may access providers who are not members of the StreetSelect network: For emergency care or When prior authorization is issued to a physician, specialist, or facility that is unavailable through the network; or To obtain a second opinion when a StreetSelect physician recommends surgery and another qualified physician within the plan is not available for consultation. Prior authorization for this referral is required If qualified physicians are available within the network, authorization may be considered for a claimant to select a treating physician outside of the network if he/she establishes by competent evidence ALL of the following: The claimant has been treated by providers solely within the StreetSelect network for a period of at least one year; and That for reasons related to the treatment alone, the claimant has not made progress toward recovery that is reasonably consistent with the treatment guidelines; and That the claimant establishes to a reasonable certainty that proposed treatment outside the network would more likely provide him/her with a better clinical outcome than the current treatment or rehabilitation plan

13 Please note: A condition of the right to opt out under this provision shall be that the services secured outside the plan are for treatment purposes only and the provider shall not be permitted to rate the claimant for permanent partial or permanent total disability. Billing Essentials and Coding Co payments or deductibles are not required or allowed for medical services rendered in connection with a work related injury or occupational disease. Prior Authorization Prior authorization is always required for those services to avoid delay and/or denial of medical reimbursement. Written authorization should be obtained from the BrickStreet claims adjuster in advance for the procedures and services listed below, except in emergencies or where the condition of the patient, in the opinion of the medical provider, is likely to be endangered by delay. Failure to comply with this rule may result in disapproval of the medical vendor s bill. This rule does not apply in cases involving initial treatment. Prior authorization required for: Transplants Joint Replacements Multidisciplinary Pain Programs Medications not on the Preferred Drug List (PDL) and after the first 12 weeks of treatment Major elective surgeries of the neck and back. Examples include: o o o o o o o Spinal Fusions Spinal Cord Stimulators and Pumps Intradiscal Electrothermal Annuloplasty (IDET) Discograms Myelograms Percutaneous Discectomy Artificial Discs Current Billing Notices will be available on

14 Workers Compensation Rule 20 The West Virginia Office of Insurance Commissioner requires all medical providers treating workers compensation claimants to comply with the rules contained in Rule 20, Medical Management of Claims, Guidelines for Impairment Evaluations, Evidence, and Ratings, and Ranges of Permanent Partial Disability Awards. StreetSelect and all participants must adhere to these standards. This Rule can be obtained from the West Virginia Secretary of State website: Electronic Invoice Submission BrickStreet Insurance offers a service for health care providers that enable invoices to be processed quickly. With the help of WINASAP2003(Accelerated Submission and Processing for All Payers) software from ACS, BrickStreet allows medical providers to transmit reimbursement for services provided to BrickStreet claims. ACS provides a transmittal response to the providers within 24 hours stating if the claim was accepted or rejected; if rejected it gives the provider justification. This allows BrickStreet to pay medical providers at a much faster pace. The WINASAP2003 software and services may be found online at: gcro.com. This software follows the format of X12, a mandated HIPAA compliant format E Comp Authorization Template Submission Now available on E comp are authorization request templates for health care providers. These templates are available for use by physicians and physical therapists, rehabilitation service providers and durable medical equipment providers. The health care provider can complete the request form on line and submit it through E Comp. Upon transmission, an image will automatically be created in our Electronic Document Management System (EDMS) and immediately be forwarded to the claim adjuster. There will be no need for the vendor to create a paper document to make a request or to incur the cost of postage. Additionally, the time and resources required to create a paper document, have it handled by the postal service, then processed by our mail room will all be eliminated, greatly speeding up service delivery to injured workers. Disposable/Non Reusable Supplies BrickStreet will reimburse for supplies prescribed by the authorized physician for use by the claimant in the home setting. Supplies include dressings, colostomy supplies, catheters, and other similar items. The claimant s related diagnosis must be stated on the prescription form. NOTE: Supplies used in an office setting will NOT be reimbursed, as payment for supplies required for professional services are included in the professional payment for Evaluation & Management, Surgery and other CPT codes

15 Health Insurance Portability and Accountability Act (HIPAA) While the provisions of HIPAA do not specifically cover workers compensation programs, we understand the impact that this regulation has on the medical providers with whom we are associated. Thus, we will strive to reduce any unnecessary encumbrances that HIPAA has on our current practices and procedures. Reimbursement Reimbursement for services depends on the proper filing of claims and meeting conditions of reimbursement. Vendors should bill for services provided to claimants as quickly as possible. Invoices must initially be submitted based upon the provider s contractual agreement with StreetSelect. All invoices must be submitted within six (6) months of the date of service, as required by statute [W.Va. Code a(2)]. The statute also prohibits any provider who has accepted an injured employee for treatment or provision of other services from making any charge against the claimant, which would result in a total charge in excess of the maximum scheduled service reimbursement. Providers must submit their charges with appropriate codes at their usual and customary charge, not the maximum amount allowed under the West Virginia Office of Insurance Commissioner fee schedule. Written descriptions of procedures alone will not be accepted. Billing must be submitted on the CMS 1500 (formerly, HCFA 1500); certain non standard services unique to StreetSelect require Service Invoice, Form BI 400, available on BrickStreet s website. Completed invoices should be mailed to BrickStreet. Request for Additional Information In certain circumstances, BrickStreet may request additional information from the provider. Upon receipt of the requested information, the pended claim will be processed. If the requested information is not received within 30 days from the date the request was sent, the invoice will be denied. When the requested information is provided to BrickStreet, the denial for payment may be reconsidered. Adjustment of Denied/Paid Invoices When payment has been denied due to missing information such as proper diagnosis as related to compensable injury, or other billing information, the invoice must be resubmitted with the requested or updated information. A request for adjustment is not necessary. When a health care provider believes a payment is incorrect or payment is due for a rejected invoice, a written explanation is required. Such requests for reconsideration are to be made with supporting documentation to BrickStreet. Coding Conventions BrickStreet, with some exceptions, uses these nationally accepted standardized code sets for reporting medical conditions and treatment:

16 Common Procedure Terminology (CPT 4) codes (HCPCS Level I codes), for provider professional services Alpha numeric codes (HCPCS Level II codes) for supplies, equipment and other medical services Local Codes (HCPCS Level III) for unique workers compensation specific services (NOTE: Use of these non standardized codes is limited as much as possible) International Classification of Diseases, Ninth Revision, Clinical Modification (ICD 9 CM) for reporting diagnoses of work related injuries and occupational illnesses. CPT 4 Codes (HCPCS Level I) BrickStreet updates the bill processing system to accept many of the new codes that are implemented nationally on an annual basis. This coding system, which uses a five digit numeric code and allows for a two digit modifier, issued to report most professional services, including Evaluation and Management, surgical intervention, anesthesia services related to surgery, physical medicine, and other professional services. HCPCS Level II National Alpha numeric Codes BrickStreet accepts many of the codes developed by CMS for reporting those medical services and supplies not addressed by the CPT 4 code set. This coding system uses a fivebyte code, which consist of one alphabetic character (a letter between and including A and V), followed by four (4) digits. The codes all begin with a single letter and are followed by four (4) digits. HCPCS codes also use modifiers, either two (2) digits or two (2) letters. HCPCS Level III Local Codes The Level III codes are assigned and maintained by individual carriers. Like the HCPCS II National Codes, these codes begin with a letter (W through Z) followed by four (4) numeric digits. The most notable difference is that these codes are not common to all carriers. West Virginia Insurance Commission workers compensation Local Codes are included in the Non RBRVS Fee file on the West Virginia Insurance Commission s website. BrickStreet utilizes the same local codes as the West Virginia Insurance Commission. ICD 9 CM Diagnosis Codes The claims administrator uses the ICD 9 CM coding system to report claimant conditions in work related injuries and occupational illnesses. The initial primary diagnostic code should be reported using the to code range. Disease claims and resulting conditions described with codes outside this range may be utilized when appropriate. A limited number of non numeric codes in the V code classification range are accepted by BrickStreet for billing purposes

17 Resource Based Relative Value Scale (RBRVS) Methodology BrickStreet uses the Resource Based Relative Value Scale system (RBRVS). It is based on work done by researchers at Harvard University and information developed at Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA). The RBRVS fee schedule addresses payments for the professional component of services provided by health care vendors in Workers Compensation claims. Conversion Factors BrickStreet utilizes two Conversion Factors (CF): one for Medical and one for Anesthesia services. The Anesthesia CF is used for anesthesia services reported with anesthesia CPT codes, and the Medical CF is used for all other services described and reported with CPT codes. Comprehensive/Component Services (Rebundling) The RBRVS system uses the American Medical Association s Current Procedural Terminology, Standard Edition (CPT) codes. Relative value units for the physician work associated with performing a procedure were developed, in general, using the definitions provided in the CPT manual, and reflects the relative resources that are required to produce a particular service. For example, Work RVUs for a comprehensive surgical procedure such as nerve decompression, or freeing of the median nerve, reflect the relative level of complexity and time required to perform the surgery. The CPT description of a neuroplasty procedure includes component procedures, such as the injection of a local infiltration. The resources required to perform component services are included in the Work RVUs for the comprehensive procedure by RBRVS policy. Under Workers Compensation rules, payment is made for the comprehensive service only, consistent with national RBRVS policy. Additional payment is not made for any of the component procedures, e.g., injection, if performed by the same physician on the same day, nor are physicians allowed to bill for the component procedures separately. Global Surgery Package Consistent with national RBRVS policy, reimbursement for a surgical procedure includes all normal and uncomplicated care for that procedure. As defined by CPT, a surgical procedure includes the operation per se; local infiltration, metacarpal digital block, or topical anesthesia, when used; and normal uncomplicated follow up care. BrickStreet uses the RBRVS timeframe to establish the global surgical period for routine pre and post operative visits. Separate charges for this routine care are not covered. Pre operative visits are defined as visits by the surgeon on the day of the surgery for minor procedures and the day before surgery, as well as the day of the surgery for major procedures. Post operative visits are defined as visits by the surgeon or other provider during a specified timeframe following surgery. The pre and post operative timeframes by type of procedure are as follows: Pre Operative Period Major 1 day 90 days Post Operative Period

18 Minor 0 days 0 10 days Endoscopic 0 days 0 10 days BrickStreet s policy requires that a single fee be billed for all necessary services normally furnished by the surgeon before, during, and after the procedure. Major surgery generally includes several services that occur on different days, while minor and endoscopic procedures may include only services that occur the day of, or within 10 days of, the surgical procedure. With global billing, all expenses related to the surgical procedure must be billed with the same date of service as the surgical procedure. MODIFIERS The most common modifiers applicable to CPT codes and specific policies pertaining to them are listed below. Definitions may be found in Current Procedural Terminology and HCPCS Level II books. Modifiers 22 and 52 Unusual or Reduced Services Increases or decreases in payment are allowed for unusual circumstances. An operative report and written description of the reason for using one of the two modifiers is required. Modifier 23 Unusual Anesthesia When anesthesia is used for a procedure that usually requires no anesthesia or local anesthesia, Modifier 23 is used. Written documentation must be provided to explain the reason for the anesthesia. This modifier is not to be used for emergency anesthesia. Modifier 24 Unrelated Evaluation and Management (E&M) Service by the same physician during a post operative period Unrelated E & M services provided during the post op period by the same physician who performed the surgical procedure are allowed at the full payment level for the service when billed with modifier 24. Modifier 25 Significant, Separately Identifiable E&M Service by the same physician on the same day of the procedure or other service. Modifier 25 is used to indicate that a patient s condition required a significant, separately identifiable E&M service that was unrelated to the usual pre and post op care associated with the procedure performed. Office notes are required when billing this modifier. Claims will be reviewed to determine if a separately identifiable service was performed. Full payment will be made for this service if it is determined to be separately identifiable. Modifier 26 and TC Professional & Technical Components Modifier 26 is used to indicate that only the professional component of a service or procedure was performed and modifier TC is used to indicate that only the technical component was provided. Modifiers 26 and TC are used for three types of services: Diagnostic and therapeutic radiology services Certain diagnostic tests that involve a physician s interpretation

19 Physician pathology services Modifier 47 Anesthesia by Surgeon Modifier 47 is used to report regional or general anesthesia provided by the surgeon. This does not include local anesthesia. Modifier 50 Bilateral Procedures Modifier 50 is used when performing a procedure on both sides of the body at the same operative session that is normally done on only one side of the body. Modifier 51 Multiple Procedures Modifier 51 is used to bill multiple surgical procedures. The highest valued procedure is paid at 100% and the second through fourth are paid at 50% of their respective values. The fifth, and all subsequent procedures, require an operative report and are paid on a by report basis after review. For certain dermatological services, separate CPT codes (and RVUs) are used to represent multiple surgical procedures. For these services, multiple procedure rules do not apply. Modifier 53 Discontinued Procedure (Physician) Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure when extenuating circumstances threaten the well being of the patient. In this situation, report the procedure by adding modifier 53 to the CPT code. This modifier is not used to report the elective cancellation of a procedure prior to induction of anesthesia and/or surgical preparation in the operating suite. Modifier 54 Surgical Care Only There may be circumstances in rural areas in which a family practitioner provides the preoperative care in anticipation of the arrival of an itinerant surgeon. The surgeon performing the surgical service only should submit a bill with modifier 54 and will receive payment for the surgery only. Modifier 55 Post Operative Management Only When a physician other than the surgeon provides post op care, modifier 55 is used to bill for that care only. Payment represents only the post operative portion of the surgical fee. Modifier 56 Pre Operative Care Only Providers responsible for the pre operative care only must use modifier 56. Payment will represent only the pre operative portion of the surgical fee. Modifier 57 Initial Decision for Surgery Modifier 57 is used to identify an evaluation and management service that resulted in the initial decision to perform surgery and that occurred during the global surgery pre operative period. Office notes are required when billing this modifier. Claims will be reviewed to determine if the E & M resulted in the decision for surgery. Full payment will be made for this service if it is determined that the E & M resulted in the decision for surgery

20 Modifier 58 Staged or Related Procedure by the Same Physician During the Post Operative Period Modifier 58 is used to identify a procedure during the post operative period that was (a) planned before the time of the original (staged) procedure; (b) more extensive than the original surgical procedure; or (c) for therapy following a diagnostic surgical procedure. Full payment will be made for these procedures, except in the case of more than one surgery being performed; in that instance, multiple surgery guidelines apply. Modifier 62 Co Surgeons When two surgeons work together to perform the same procedure (same CPT code) and provide separate services during the same procedure, each physician is considered a cosurgeon. Medicare s requirement that the surgeons be from different specialties does not apply. Each physician must submit a claim with modifier 62 added to the procedure code. Each surgeon will be paid 62.5% of the global surgery fee allowance. The billing of an assistant at surgery is not allowed when the surgery is performed by co surgeons. Modifier 66 Team Surgery When more than two surgeons from different specialties work together to perform the same procedure (same CPT code) and provide separate services during the same procedure, each physician is considered to be a member of a surgical team. Each physician must submit a claim with modifier 66 added to the procedure code. Billing for an assistant at surgery is not allowed when team surgery is performed. An operative report must be submitted when modifier 66 is used. Such invoices will be reviewed and priced on a case by case basis. Modifier 76 Repeat Procedure by Same Physician Modifier 76 is used when a repeat procedure is performed by the same physician during the global period. Full payment will be made for the procedure. Modifier 77 Repeat Procedure by Another Physician Modifier 77 is used when a repeat procedure is performed by another physician during the global period. Full payment will be made for the procedure. Modifier 78 Return Trip to the Operating Room Modifier 78 is used when a return trip to the operating room for another procedure is necessary within the global surgical period. All claims with modifier 78 will be subject to review regarding payment. Modifier 79 Procedures Unrelated to Original Procedure Performed by Same Physician Modifier 79 is used when necessary procedures unrelated to the original procedure are performed by the same physician within the global post operative period. All claims with modifier 79 will be subject to review. Modifiers 80, 81, and 82 Assistant at Surgery The primary surgeon receives 100% of the global surgery fee allowance and the assistant atsurgery receives 16% of the global surgery fee allowance. Modifier 80 Surgical Assistant services

21 Modifier 81 Minimum Assistant Surgeon service Modifier 82 Assistant Surgeon (Qualified Resident not available). Modifier QZ Nurse Anesthetist w/o Medical Direction Modifier QZ is used to submit claims for services of a nurse anesthetist without medical direction as part of an anesthesia team. Modifier QX Nurse Anesthetist Modifier QX is used to submit claims for services of a nurse anesthetist acting as part of an anesthesia team. Modifier QY Supervisory Anesthesia Modifier QY is used to identify claims that are submitted by anesthesiologists acting as part of an anesthesia team. Modifier AA Anesthesia by Physician Only Modifier AA is used to identify claims that are submitted by anesthesiologists acting without a CRNA or PA. Modifier AD Supervisory Anesthesia of more than 4 Modifier AD is used to identify claims that are submitted by anesthesiologists acting as part of an anesthesia team with more than 4 procedures being supervised. Modifier QK Supervisory Anesthesia of 2, 3 or 4 Modifier AD is used to identify claims that are submitted by anesthesiologists acting as part of an anesthesia team with 2, 3 or 4 procedures being supervised. Modifier SG Ambulatory Surgical Center Modifier SG is used to identify claims that are submitted by a Medicare approved ASC for the facility fee portion of the service. Modifier 99 Multiple Modifiers Under certain circumstances two or more modifiers may be necessary to completely delineate a service. In such situations, modifier 99 should be added to the basic procedure, and other applicable modifiers listed as part of the description of the service. Any bill with modifier 99 is subject to manual review to ensure appropriate payment, and a written report explaining the multiple modifiers is required. DME Modifiers (Per HCPCS Level II) NU new RR rental LT Left side (Hearing Aid) RT Right side (Hearing Aid) MS Three Month Maintenance (O 2 Concentrators) If not billed with a modifier the code may be denied

22 Practice Expense To determine the correct allowance for a specific procedure, the Place of Service indicator must be considered. If the procedure is carried out in a provider s office, the Non Facility Practice Expense Relative Value Unit will be used to calculate payment. If the procedure is performed in a facility setting, the Facility Practice Expense Relative Value Unit will be used to calculate payment. Code Narrative Code Narrative 11 Office 51 Psychiatric Facility (Inpatient) 12 Home 52 Psychiatric Facility (Outpatient) 21 Hospital (Inpatient) 53 Community Mental Health Center 22 Hospital (Outpatient) 54 Intermediate Care Facility 23 Hospital (Emergency Dept.) 55 Residential Substance Abuse Facility 24 Ambulatory Surgical Center Psychiatric Residential Treatment 56 (ASC) Cent. 25 Birthing Center 60 Mass Immunization Center 26 Military Treatment Facility 61 Comprehensive Inpatient Rehab Center 31 Skilled Nursing Facility 62 Comprehensive Outpatient Rehab Fac. 32 Nursing Facility 65 End Stage Renal Treatment Facility 33 Custodial Care Facility 71 State or Local Public Health Clinic 34 Hospice 72 Rural Health Clinic 41 Ambulance (Land) 81 Independent Lab 42 Ambulance (Air and Water) 99 Other Unlisted Facility By Report Services/Unlisted Procedures By Report Services are unusual, variable, or too new to be assigned a fee. A detailed report with the following information concerning the nature, extent, and need for the procedure or service, the time, skill, and the equipment necessary along with a proposed fee, etc., is to be furnished to the claims administrator before services are rendered. When emergency circumstances necessitate the performance of a By Report procedure, the documentation noted above must be submitted to the Claims Representative. Injections Injections are reimbursable under the RBRVS, and there are RVUs identified for these services. However, they are only payable under the physician fee schedule if there are no other services billed by the same provider on the same date of service. If any other services that are payable under the fee schedule are billed by the provider on the same day, then the injection services are bundled into the service(s) for which payment is made. Anesthesia Generally, Medicare s payment methodology is used with a separate conversion factor for anesthesia services. The following policies apply for anesthesia services:

23 American Society of Anesthesiologists (ASA) Uniform Relative Value Guide; CPT anesthesia codes; ASA s definition of anesthesia time; CMS attending physician relationship policy whereby this relationship is only recognized when the anesthesiologist is involved in a single procedure with an intern or resident. The following payment methodologies differ from those used by Medicare: Parity in Payment Non medically directed CRNAs are paid at parity with anesthesiologists, when personally providing anesthesia or other medical services within the scope of a CRNA s license. Time Units Whole time units are used. If total minutes exceed a 15 minute interval, one additional unit is paid. Anesthesia Teams An anesthesia team is defined to include one anesthesiologist and one CRNA per patient. Anesthesiologists may supervise up to 4 CRNAs. The total payment level for the anesthesia team is 100 percent of the payment level for an anesthesiologist performing individually. The payment is split to allow 60 percent to the anesthesiologist and 40 percent to the medically directed CRNA. Pathology and Laboratory Services Only the professional component of physician pathology services is paid if performed in the hospital; the professional and technical components are paid if performed by an independent lab. The technical component, if performed as an inpatient service, is paid under the current inpatient reimbursement methodology. Payment for non physician pathology services is based on the Lab Fee Schedule (see the Non RBRVS Workers Compensation Fee Schedule found on the West Virginia Insurance Commission s website.) Medicare s policies for clinical lab interpretation services and consultative pathology services are used. Payment for collection of specimens through venipuncture or catheterization is included in the payment for the lab procedure when the specimen is collected by the lab which processes the specimen. Laboratory Certification To bill, a lab must have a certificate of registration through the Clinical Laboratory Improvement Act of 1988 (CLIA). Hospital Outpatient Facility Laboratory Payment Payment for diagnostic and laboratory services when provided in an outpatient hospital facility is reimbursed based upon one of the following fee schedules: RBRVS fee schedule for diagnostic X rays and clinical pathology services or Clinical Laboratory fee schedule for all clinical laboratory services

24 Surgery Services BrickStreet utilizes Medicare s policies for surgical service reimbursements. In addition to the Global Surgery Period referenced above, BrickStreet uses the various surgical indicators used by Medicare for claim processing surgical services. For procedure codes that are designated by Medicare for policy inclusion, the adjustments include: Multiple Surgery Major surgery is paid at 100% of fee or billed amount, which ever is lower. Same day procedures may be reduced by 50% of the fee or the billed amount, whichever is lower. Bilateral Surgery Bilateral surgery is paid at 150% of fee or billed amount, which ever is lower, for both procedures. Assistant Surgery Assistant surgery is paid at 16% of fee or billed amount, which ever is lower, for assistant surgery services. Co Surgery The total payment for Co Surgeons is split between the two surgeons, with the total payment being 125% of fee or billed amount, whichever is lower, for both providers. Team Surgery The total payment for Team Surgeons is split amongst between the surgeons, with the total payment being 125% of fee or billed amount, which ever is lower, for all providers. Ambulatory Surgical Center Facility fees for certain surgical procedures may be reimbursable when they are performed in a Medicare certified Ambulatory Surgical Center (ASC). Providers that have such certification and wish to bill for ACS charges should contact the Provider Registration unit of Medical & Provider Relations of BrickStreet to ensure that their certification is on file with BrickStreet. ASC providers are to bill the facility fee by using the surgical CPT code with the modifier SG. Diagnostic Testing and Radiology Procedures Electromyography and Nerve Conduction Tests must be personally performed by a physician or a physical therapist who is certified by the American Board of Physical Therapy Specialties as a qualified electrophysiologic clinical specialist and who is permitted to provide the service under State law. NOTE: Surface EMGs and Thermography are non covered. Provider NPI Requirement BrickStreet Insurance requires all providers to submit their NPI Number on all Health Insurance Forms (UB04 (formerly UB92, CMS1500 (formerly HCFA 1500) and BI400 BrickStreet Service Invoice)

25 All health care professionals providing services for BrickStreet Insurance and those that are eligible for a Center for Medicare and Medicaid NPI Number must submit this number on all types of billing invoice submissions to be considered for reimbursement. Those providers not eligible or those who have chosen not to apply for the NPI must submit their BrickStreet individual professional provider number. Official Disability Guidelines (ODG) StreetSelect has adopted the national medical treatment protocols of The Official Disability Guidelines (ODG) developed by Work Loss Data Institute. StreetSelect will use these protocols as guides to evaluate care rendered. Retrospective review of claims will be made and feedback will be given as appropriate. ODG protocols provide consistent, standard criteria for measuring quality care, related resource utilization, and costs. These protocols serve as a decision support tool for reviewing the diagnosis, treatment selection, resource selection, and acute care management of specific illnesses. Provider Remedial Action BrickStreet will expect all providers to comply with treatment standards. If exceptions are necessary in individual cases, the provider must document the reasons for exceptions. These will be subject to peer review through the Medical Director and/or Medical Advisory Board. StreetSelect s Provider Utilization Review Unit will monitor provider performance in relation to treatment standards and identify those providers who develop a pattern of performance outside of accepted standards and refer related documentation to the Medical Advisory Board. Once the Board verifies the performance data, StreetSelect will notify the provider of the nature of the exception with the expectation that remedial action must be taken within the next quarter. If performance indicators do not approximate the standard at the end of the quarter, the provider will be placed in a probationary status for six months. If compliance is not achieved within the probationary period, the provider will be dismissed from the network. Immediate dismissal, pending investigation, will be invoked with any provider who is engaged in detrimental criminal behavior or who is practicing in a manner appearing to pose an unusual or extraordinary risk to the health, welfare, or safety of patients. The provider will have the right to request a Dispute Resolution, should any decision be made that is not accepted. See the Dispute Resolution process, listed below. Medical Necessity Review Utilization Review BrickStreet has established procedures and oversight for utilization review of medical services to assure that a course of treatment is medically necessary; diagnostic procedures are not unnecessarily duplicated; the frequency, scope, and duration of treatment is