| (a) Specific provisions contained in the Labor Code
or division rules, including this chapter, take precedence over any
conflicting provision adopted or used by the Centers for Medicare
and Medicaid Services (CMS) in administering the Medicare program.
Independent review organization decisions on medical necessity made
in accordance with Labor Code §413.031 and §133.308 of this
title, which are made on a case-by-case basis, take precedence, in
that case only, over any division rules and Medicare payment policies.
(b) Payment policies relating to coding, billing, and
reporting for workers' compensation specific codes, services, and
programs are as follows:
(1) Health care providers must bill their usual and
customary charges using the most current Level I Current Procedural
Terminology (CPT) and Level II Healthcare Common Procedure Coding
System (HCPCS) codes. Health care providers must submit medical bills
in accordance with the Labor Code and division rules.
(2) Modifying circumstance must be identified by use
of the appropriate modifier following the appropriate Level I (CPT
codes) and Level II HCPCS codes. Where HCPCS modifiers apply, insurance
carriers must treat them in accordance with Medicare and Texas Medicaid
rules. In addition, division-specific modifiers are identified in
subsection (f) of this section. When two or more modifiers apply to
a single HCPCS code, indicate each modifier on the bill.
(3) A 10% incentive payment must be added to the maximum
allowable reimbursement (MAR) for services outlined in §§134.220,
134.225, 134.235, 134.240, 134.250, and 134.260 of this title and
subsection (d) of this section that are performed in designated workers'
compensation underserved areas in accordance with §134.2 of this
title. However, reimbursement for a missed appointment under §134.240
does not qualify for the 10% incentive payment.
(4) Fees established in §§134.235, 134.240,
134.250, and 134.260 of this title will be:
(A) adjusted once by applying the Medicare Economic
Index (MEI) percentage adjustment factor for the period 2009 - 2024.
(B) adjusted annually by applying the MEI percentage
adjustment factor identified in §134.203(c)(2).
(C) rounded to whole dollars by dropping amounts under
50 cents and increasing amounts from 50 to 99 cents to the next dollar.
For example, $1.39 becomes $1 and $2.50 becomes $3.
(D) effective on January 1 of each new calendar year.
(c) When there is a negotiated or contracted amount
that complies with Labor Code §413.011, reimbursement must be
the negotiated or contracted amount that applies to the billed services.
(d) When billing for services in §§134.215,
134.220, 134.225, or 134.230, and there is no negotiated or contracted
amount that complies with Labor Code §413.011, reimbursement
must be the least of the:
(1) MAR amount;
(2) health care provider's usual and customary charge;
or
(3) fair and reasonable amount consistent with the
standards of §134.1 of this title.
(e) For services provided under §§134.235,
134.240, 134.250, or 134.260, health care providers must bill and
be reimbursed the MAR.
(f) The following division modifiers must be used by
health care providers billing professional medical services for correct
coding, reporting, billing, and reimbursement of the procedure codes.
(1) 25--This modifier must be added to CPT code 99456
when the division ordered the designated doctor to perform an examination
of an injured employee with one or more of the diagnoses listed in §127.130(b)(9)(B)
- (I) of this title.
(2) 52--This modifier must be added to CPT code 99456
when the division ordered the designated doctor to perform an examination
of an injured employee, and the injured employee failed to attend
the examination.
(3) CA, Commission on Accreditation of Rehabilitation
Facilities (CARF) accredited programs--This modifier must be used
when a health care provider bills for a return-to-work rehabilitation
program that is CARF accredited.
(4) CP, chronic pain management program--This modifier
must be added to CPT code 97799 to indicate chronic pain management
program services were performed.
(5) FC, functional capacity--This modifier must be
added to CPT code 97750 when a functional capacity evaluation is performed.
(6) MR, outpatient medical rehabilitation program--This
modifier must be added to CPT code 97799 to indicate outpatient medical
rehabilitation program services were performed.
(7) MI, multiple impairment ratings--This modifier
must be added to CPT code 99456 when the designated doctor is required
to complete multiple impairment ratings calculations.
(8) NM, not at maximum medical improvement (MMI)--This
modifier must be added to the appropriate MMI CPT code to indicate
that the injured employee has not reached MMI when the purpose of
the examination was to determine MMI.
(9) VR, review report--This modifier must be added
to CPT code 99455 to indicate that the service was the treating doctor's
review of reports only.
(10) V3, treating doctor evaluation of MMI--This modifier
must be added to CPT code 99455 when the office visit level of service
is equal to CPT code 99213.
(11) V4, treating doctor evaluation of MMI--This modifier
must be added to CPT code 99455 when the office visit level of service
is equal to CPT code 99214.
(12) V5, treating doctor evaluation of MMI--This modifier
must be added to CPT code 99455 when the office visit level of service
is equal to CPT code 99215.
(13) WC, work conditioning--This modifier must be added
to CPT codes 97545 and 97546 to indicate work conditioning was performed.
(14) WH, work hardening--This modifier must be added
to CPT codes 97545 and 97546 to indicate work hardening was performed.
(15) W1, case management for treating doctor--This
modifier must be added to the appropriate case management billing
code activities when performed by the treating doctor.
(16) W5, designated doctor examination for impairment
or attainment of MMI--This modifier must be added to the appropriate
examination code performed by a designated doctor when determining
impairment caused by the compensable injury and in attainment of MMI.
(17) W6, designated doctor examination for extent--This
modifier must be added to the appropriate examination code performed
by a designated doctor when determining extent of the injured employee's
compensable injury.
(18) W7, designated doctor examination for disability--This
modifier must be added to the appropriate examination code performed
by a designated doctor when determining whether the injured employee's
disability is a direct result of the work-related injury.
(19) W8, designated doctor examination for return to
work--This modifier must be added to the appropriate examination code
performed by a designated doctor when determining the ability of the
injured employee to return to work.
(20) W9, designated doctor examination for other similar
issues--This modifier must be added to the appropriate examination
code performed by a designated doctor when determining other similar
issues.
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