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(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 September 1, 2002. For professional medical services provided prior to September 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 (the Act), or Texas Workers' Compensation Commission (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. Independent Review Organization (IRO) decisions regarding medical necessity are made on a case-by-case basis. The commission will monitor IRO decisions to determine whether commission rulemaking action would be appropriate. (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 125%. For Anesthesiology services, the same conversion factor shall be used. (2)for Healthcare Common Procedure Coding System (HCPCS) Level II codes A, E, J, K, and L: (A)125% 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, 125% 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 pathology and laboratory services not addressed in subsection (c)(1) or in other commission rules: (A)125% of the fee listed for the code in the Medicare Clinical Fee Schedule for the technical component of the service; and, (B)45% of the commission established MAR for the code derived in subparagraph (A) for the professional component of the service. (4)for dental treatments and services 125% 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 commission 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 American Medical Association (AMA) Physician's Current Procedural Terminology (CPT) code. Additionally, commission specific modifiers are identified in paragraph (9) of this subsection. When two modifiers are applicable to a single CPT 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)Functional Capacity Evaluations (FCEs). A maximum of three 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 in accordance with subsection (c)(1). Reimbursement shall be for up to a maximum of four hours for the initial test or for a commission ordered test; a maximum of two hours for an interim test; and, a maximum of three hours for the discharge test, unless it is the initial test. Documentation is required. FCEs shall include the following elements: (A)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. (B)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. (C)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. To qualify as a commission Return to Work Rehabilitation Program, a program should meet the "Specific Program Standards" for the program as listed in the most recent Commission on Accreditation of Rehabilitation Facilities (CARF) Medical Rehabilitation Standards Manual. Section 1 standards regarding Organizational Leadership, Management and Quality apply only to CARF accredited programs. (A)Accreditation by the CARF is recommended, but not required. (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 commission purposes, General Occupational Rehabilitation Programs, as defined in the CARF manual, 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 1 hour shall be prorated by 15 minute increments. A single 15 minute increment may be billed and reimbursed if greater than or equal to 8 minutes and less than 23 minutes. (C)Work Hardening/Comprehensive Occupational Rehabilitation Programs (for commission purposes, Comprehensive Occupational Rehabilitation Programs, as defined in the CARF manual, 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 1 hour shall be prorated by 15 minute increments. A single 15 minute increment may be billed and reimbursed if greater than or equal to 8 minutes and less than 23 minutes. (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 1 hour shall be prorated by 15 minute increments. A single 15 minute increment may be billed and reimbursed if greater than or equal to 8 minutes and less than 23 minutes. (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 1 hour shall be prorated in 15 minute increments. A single 15 minute increment may be billed and reimbursed if greater than or equal to 8 minutes and less than 23 minutes. (6)Maximum Medical Improvement and/or Impairment Rating (MMI/IR) examinations shall be billed and reimbursed as follows: (A)The total MAR for an MMI/IR examination shall be equal to the MMI evaluation reimbursement plus the reimbursement for the body area(s) evaluated for the assignment of an IR. The MMI/IR examination 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; and, (v)tests used to assign the IR, as outlined in the AMA Guides to the Evaluation of Permanent Impairment (the AMA Guides), as stated in the commission Act and Rules, Chapter 130 relating to Impairment and Supplemental Income Benefits. (B)A HCP shall only bill and be reimbursed for an MMI/IR examination if the doctor performing the evaluation (i.e., the examining doctor) is an authorized doctor in accordance with the Act and commission Rules, Chapter 130 relating to Certification of Maximum Medical Improvement and Evaluation of Permanent Impairment. (i)If the examining doctor, other than the treating doctor, determines MMI has not been reached, the MMI evaluation portion of the examination shall be billed and reimbursed in accordance with subparagraph (C). Modifier "NM" shall be added. (ii)If the examining doctor determines MMI has been reached and there is no permanent impairment because the injury was sufficiently minor, an IR evaluation is not warranted and only the MMI evaluation portion of the examination shall be billed and reimbursed in accordance with subparagraph (C). (iii)If the examining doctor determines MMI has been reached and an IR evaluation is performed, both the MMI evaluation and the IR evaluation portions of the examination shall be billed and reimbursed in accordance with subparagraphs (C) and (D). (C)The following applies for billing and reimbursement of an MMI evaluation. (i)An examining doctor who is the treating doctor shall bill using the "Work related or medical disability examination by the treating physician..." CPT code with the appropriate modifier. (I)Reimbursement shall be the applicable established patient office visit level associated with the examination. (II)Modifiers "V1", "V2", "V3", "V4", or "V5" shall be added to the CPT code to correspond with the last digit of the applicable office visit. (ii)If the treating doctor refers the injured employee to another doctor for the examination and certification of MMI (and IR); and, the referral examining doctor has: (I)previously been treating the injured employee, then the referral doctor shall bill the MMI evaluation in accordance with subparagraph (C)(i); or, (II)not previously treated the injured employee, then the referral doctor shall bill the MMI evaluation in accordance with subparagraph (C)(iii). (iii)An examining doctor, other than the treating doctor, shall bill using the "Work related or medical disability examination by other than the treating physician..." CPT code. Reimbursement shall be $350. (D)The following applies for billing and reimbursement of an IR evaluation. (i)The HCP shall include billing components of the IR evaluation with the applicable MMI evaluation CPT code. The number of body areas rated shall be indicated in the units column of the billing form. (ii)When multiple IRs are required as a component of a designated doctor examination under §130.6 of this title (relating to Designated Doctor Examinations for Maximum Medical Improvement and/or Impairment Ratings), the designated doctor shall bill for the number of body areas rated and be reimbursed $50 for each additional IR calculation. Modifier "MI" shall be added to the MMI evaluation CPT code. (iii)For musculoskeletal body areas, the examining doctor may bill for a maximum of three 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 as follows. (-a-)$150 for each body area if the Diagnosis Related Estimates (DRE) method found in the AMA Guides 4th edition is used. (-b-)If full physical evaluation, with range of motion, is performed: (-1-)$300 for the first musculoskeletal body area; and, Cont'd...
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