Texas Register

TITLE 28 INSURANCE
PART 2TEXAS WORKERS' COMPENSATION COMMISSION
CHAPTER 134BENEFITS--GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS
SUBCHAPTER CMEDICAL FEE GUIDELINES
RULE §134.202Medical Fee Guideline
ISSUE 12/28/2001
ACTION Proposed
Preamble No Rule Available

(a)Applicability of this rule is as follows:

  (1)This section applies to professional medical services (health care other than prescription drugs or medicine, and the facility services of a hospital or other health care facility) provided in the Texas Workers' Compensation system.

  (2)This section shall be applicable for professional medical services provided on or after June 1, 2002. For professional medical services provided prior to June 1, 2002, §134.201 and §134.302 of this title (relating to Medical Fee Guidelines) shall be applicable.

  (3)Notwithstanding Centers for Medicare and Medicaid Services (CMS) payment policies, chiropractors may be reimbursed for services provided within the scope of their practice act.

  (4)Specific provisions contained in the Texas Workers' Compensation Act (Act), or commission rules, including this rule, shall take precedence over any conflicting provision adopted by or utilized by CMS in administering the Medicare program. Exceptions to Medicare payment policies for medical necessity may be provided by commission rule or through medical dispute resolution in accordance with the Act and commission rules.

  (5)Whenever a component of the Medicare program is revised and effective, use of the revised component shall be required for compliance with commission rules, decisions and orders for services rendered on or after the effective date of the revised component.

(b)For coding, billing, reporting, and reimbursement of professional medical services, Texas Workers' Compensation system participants shall apply the Medicare program reimbursement methodologies, models, and values or weights including its coding, billing, and reporting payment policies in effect on the date a service is provided with any additions or exceptions in this section.

(c)To determine the maximum allowable reimbursements (MARs) for professional services system participants shall apply the Medicare payment policies with the following minimal modifications:

  (1)for service categories of Evaluation & Management, General Medicine, Physical Medicine and Rehabilitation, Surgery, Radiology, and Pathology the conversion factor to be used for determining reimbursement in the Texas workers' compensation system is the effective conversion factor adopted by CMS multiplied by 120%. For Anesthesiology services, the same conversion factor shall be used.

  (2)for HCPCS Level II codes A, E, J. K, and L:

    (A)120% of the fee listed for the code in the Medicare Durable Medical Equipment, Prosthethics, Orthotics and Supplies (DMEPOS) fee schedule;

    (B)if the code has no published Medicare rate, 120% of the published Texas Medicaid Fee Schedule Durable medical Equipment/Medical Supplies Report J, for HCPCS; or

    (C)if neither paragraph (2)(A) nor (2)(B) of this section apply, then as calculated according to paragraph (6) of this subsection.

  (3)for laboratory services 120% of the fee listed for the code in the Medicare Clinical Fee Schedule.

  (4)for dental treatments and services 120% of the fee listed for the code in the Texas Medicaid Dental Fee Schedule in effect on the date the service is provided.

  (5)for commission specific codes, services and programs (e.g. Functional Capacity Evaluation, Impairment Rating Evaluations, Return to Work Programs, etc.) as calculated in accordance with subsection (e) of this section.

  (6)for products and services for which CMS or the Commission does not establish a relative value unit and/or a payment amount the carrier shall assign a relative value, which may be based on nationally recognized published relative value studies, published medical dispute decisions, and values assigned for services involving similar work and resource commitments.

(d)In all cases, reimbursement shall be the least of the:

  (1)MAR amount as established by this rule;

  (2)health care provider's usual and customary charge; or,

  (3)health care provider's workers' compensation negotiated and/or contracted amount that applies to the billed service(s).

(e)Payment Policies Relating to Coding, Billing, and Reporting for commission-specific codes, services, and programs are as follows:

  (1)Billing. Health care providers (HCPs) shall bill their usual and customary charges. HCPs shall submit medical bills in accordance with subsection (b), the Act, and commission rules.

  (2)Modifiers. Modifying circumstance shall be identified by use of the appropriate modifier following the appropriate CPT code. Additionally, commission specific modifiers are identified in paragraph (10) of this subsection. When two modifiers are applicable to a single code, indicate each modifier on the bill.

  (3)Case Management. Case Management is the responsibility of the treating doctor. Team conferences and phone calls shall include coordination with an interdisciplinary team (members shall not be employees of the coordinating HCP and the coordination must be outside of an interdisciplinary program). Documentation shall include the name and specialty of each individual attending the team conference or engaged in a phone call. Team conferences and phone calls should be triggered by a documented change in the condition of the injured employee and performed for the purpose of coordination of medical treatment and/or return to work for the injured employee. Contact with one or more members of the interdisciplinary team more often than once every 30 days shall be limited to the following:

    (A)The development or revision of a treatment plan;

    (B)To alter or clarify previous instructions;

    (C)To coordinate the care of employees with catastrophic or multiple injuries requiring multiple specialties; or,

    (D)To coordinate with the employer, employee, and/or an assigned medical or vocational case manager to determine return to work options.

  (4)Tests and Measurements. The following provisions apply to Tests and Measurements services:

    (A)Tests and Measurements Current Procedural Terminology (CPT) codes require a report of the results, to include the start and end times. No additional reimbursement shall be allowed for this report.

    (B)Job site visit/assessment shall be billed using the "Community/work reintegration training..." CPT code with modifier "JA". Job site visit/assessments shall be reimbursed at $25.00 per 15 minutes.

    (C)A maximum of three Functional Capacity Evaluations (FCEs) for each compensable injury shall be billed and reimbursed. FCEs ordered by the Commission shall not count toward the three FCEs allowed for each compensable injury. FCEs shall be billed using the "Physical performance test or measurement..." CPT code with modifier "FC." FCEs shall be reimbursed at $25 per 15-minute increment up to a maximum of five hours ($500) for the first test and for a Commission ordered test; and, a maximum of two hours ($200) for a second and/or third test. FCEs shall include the following elements:

      (i)A physical examination and neurological evaluation, which include the following:

        (I)appearance (observational and palpation);

        (II)flexibility of the extremity joint or spinal region (usually observational);

        (III)posture and deformities;

        (IV)vascular integrity;

        (V)neurological tests to detect sensory deficit;

        (VI)myotomal strength to detect gross motor deficit; and

        (VII)reflexes to detect neurological reflex symmetry.

      (ii)A physical capacity evaluation of the injured area, which includes the following:

        (I)range of motion (quantitative measurements using appropriate devices) of the injured joint or region; and

        (II)strength/endurance (quantitative measures using accurate devices) with comparison to contralateral side or normative data base. This testing may include isometric, isokinetic, or isoinertial devices in one or more planes.

      (iii)Functional abilities tests, which include the following:

        (I)activities of daily living (standardized tests of generic functional tasks such as pushing, pulling, kneeling, squatting, carrying, and climbing);

        (II)hand function tests which measure fine and gross motor coordination, grip strength, pinch strength, and manipulation tests using measuring devices;

        (III)submaximal cardiovascular endurance tests which measure aerobic capacity using stationary bicycle or treadmill; and

        (IV)static positional tolerance (observational determination of tolerance for sitting or standing).

  (5)Return To Work Rehabilitation Programs. The following shall be applied for billing and reimbursement of Work Conditioning/General Occupational Rehabilitation Programs, Work Hardening/Comprehensive Occupational Rehabilitation Programs, Chronic Pain Management/Interdisciplinary Pain Rehabilitation Programs, and Outpatient Medical Rehabilitation Programs.

    (A)Accreditation by the Commission for Accreditation of Rehabilitation Facilities (CARF) is recommended, but not required. To qualify as a Return to Work Rehabilitation Program, a program should meet the clinical standards for the program as listed in the most recent CARF Medical Rehabilitation Standards Manual.

      (i)If the program is CARF accredited, modifier "CA" shall follow the appropriate program modifier as designated for the specific programs listed below. The hourly reimbursement for a CARF accredited program shall be 100% of the MAR.

      (ii)If the program is not CARF accredited, the only modifier required is the appropriate program modifier. The hourly reimbursement for a non-CARF accredited program shall be 80% of the MAR.

    (B)Work Conditioning/General Occupational Rehabilitation Programs (for TWCC purposes, CARF accredited General Occupational Rehabilitation Programs are considered Work Conditioning.)

      (i)The first two hours of each session shall be billed and reimbursed as one unit, using the "Work hardening/conditioning; initial 2 hours" CPT code with modifier "WC." Each additional hour shall be billed using the "Work hardening/conditioning; each additional hour" CPT code with modifier "WC." CARF accredited Programs shall add "CA" as a second modifier.

      (ii)Reimbursement shall be $36.00 per hour. Units of less than 31 minutes shall not be billed or reimbursed.

    (C)Work Hardening/Comprehensive Occupational Rehabilitation Programs (for TWCC purposes, CARF accredited Comprehensive Occupational Rehabilitation Programs are considered Work Hardening.)

      (i)The first two hours of each session shall be billed and reimbursed as one unit, using the "Work hardening/conditioning; initial 2 hours" CPT code with modifier "WH." Each additional hour shall be billed using the "Work hardening/conditioning; each additional hour" CPT code with modifier "WH." CARF accredited Programs shall add "CA" as a second modifier.

      (ii)Reimbursement shall be $64.00 per hour. Units of less than 31 minutes shall not be billed or reimbursed.

    (D)Outpatient Medical Rehabilitation Programs

      (i)Program shall be billed and reimbursed using the "Unlisted physical medicine/rehabilitation service or procedure" CPT code with modifier "MR" for each hour. The number of hours shall be indicated in the units column on the bill. CARF accredited Programs shall add "CA" as a second modifier.

      (ii)Reimbursement shall be $90.00 per hour. Units of less than 31 minutes shall not be billed or reimbursed.

    (E)Chronic Pain Management/Interdisciplinary Pain Rehabilitation Programs

      (i)Program shall be billed and reimbursed using the "Unlisted physical medicine/rehabilitation service or procedure" CPT code with modifier "CP" for each hour. The number of hours shall be indicated in the units column on the bill. CARF accredited Programs shall add "CA" as a second modifier.

      (ii)Reimbursement shall be $125.00 per hour. Units of less than 31 minutes shall not be billed or reimbursed.

  (6)Maximum Medical Improvement and/or Impairment Rating (MMI/IR). MMI/IR shall be billed and reimbursed as follows.

    (A)The total MAR for an MMI/IR examination shall be equal to the MMI examination reimbursement plus the reimbursement for the body area(s) rated for the assignment of an IR. The total MAR for determination of MMI/IR shall include:

      (i)the examination;

      (ii)consultation with the injured employee;

      (iii)review of the records and films;

      (iv)the preparation and submission of reports (including the narrative report, and responding to the need for further clarification, explanation, or reconsideration), calculation tables, figures, and worksheets;

      (v)range of motion, strength and sensory testing, and measurements; and,

      (vi)other tests used to validate the IR, as outlined in the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment (the Guides).

    (B)For IR testing, the HCP shall indicate the number of body areas rated in the units column of the billing form. Body areas shall be billed and reimbursed as follows:

      (i)The examining doctor may bill for a maximum of three musculoskeletal body areas.

        (I)Musculoskeletal body areas are defined as follows:

          (-a-)spine and pelvis;

          (-b-)upper extremities and hands; and,

          (-c-)lower extremities (including feet).

        (II)The MAR for musculoskeletal body areas shall be:

          (-a-)one musculoskeletal body area: $300.00; and,

          (-b-)each additional musculoskeletal body area: $150.00.

        (III)When the examining doctor conducts the MMI examination and the IR testing, the examining doctor shall bill using the appropriate MMI/IR code with modifier "WP." Reimbursement shall be 100% of the total MAR.

        (IV)If the examining doctor conducts the MMI examination and determines the assignment of IR, excluding the testing, then the examining doctor shall bill using the appropriate MMI/IR code with CPT modifier "26." Reimbursement shall be 80% of the total MAR.

        (V)If testing is performed by a HCP other than the examining doctor, then the HCP shall bill using the appropriate MMI/IR code with modifier "TC." Reimbursement shall be 20% of the total MAR.

      (ii)Non-musculoskeletal body areas shall be billed and reimbursed using the appropriate CPT code(s) for the tests required for the assignment of IR.

        (I)Non-musculoskeletal body areas are as follows:

          (-a-)body systems;

          (-b-)body structures (including skin); and,

          (-c-)mental and behavioral disorders.

        (II)For a complete list of non-musculoskeletal body areas refer to the Guides, as stated in the commission Act and Rules Chapter 130 relating to Impairment and Supplemental Income Benefits.

    (C)When testing is required for the assignment of IR and the examining doctor refers the testing to a specialist, then the following shall apply:

      (i)The examining doctor (e.g., the referring doctor) shall bill specialist referred testing as one unit on the billing form using the appropriate MMI/IR CPT code with modifier "SP." Reimbursement shall be $50.00 for incorporating one or more specialists' report information into the final IR. This reimbursement shall be allowed only once per examination.

      (ii)The referral specialist shall bill and be reimbursed for the appropriate CPT code(s) for the tests required for the assignment of IR. Documentation is required.

    (D)Testing that falls outside of what is outlined in the Guides, but is required for the determination of MMI and/or the assignment of an IR, shall be billed using the appropriate CPT codes and reimbursed in addition to fees outlined in this section.

    (E)When the result of the evaluation is that MMI has not been reached, the total reimbursement shall be equal to the reimbursement for the determination of MMI. This reimbursement shall include all services required for an MMI/IR examination excluding those services unique to assigning an IR. The examining doctor shall bill using the appropriate MMI/IR CPT code with modifier "NM."

    (F)The treating doctor shall bill for an MMI/IR examination using the "Work related or medical disability examination by the treating physician..." CPT code with the appropriate modifier.

      (i)Reimbursement for the determination of MMI shall be the applicable established patient office visit level associated with the examination. Modifiers "V1", "V2", "V3", "V4", or "V5" shall be added to the MMI/IR examination CPT code to correspond with the last digit of the applicable office visit.

      (ii)Reimbursement for the determination of an IR shall be according to the areas rated.

      (iii)If the treating doctor refers the injured employee to another doctor for the certification of MMI and assignment of IR and the referral doctor has:

        (I)not previously treated the injured employee, then the referral doctor shall bill using the "Unlisted evaluation and management service" CPT code and the reimbursement shall be as outlined in subsection (H) for Required Medical Examinations (RME); or,

Cont'd...

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