| (A) activities of daily living (standardized tests
of generic functional tasks such as pushing, pulling, kneeling, squatting,
carrying, and climbing);
(B) hand function tests that measure fine and gross
motor coordination, grip strength, pinch strength, and manipulation
tests using measuring devices;
(C) submaximal cardiovascular endurance tests which
measure aerobic capacity using stationary bicycle or treadmill; and
(D) static positional tolerance (observational determination
of tolerance for sitting or standing).
(h) The following shall be applied to Return To Work
Rehabilitation Programs 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 Division 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, which includes
active participation in recovery and return to work planning by the
injured employee, employer and payor or carrier.
(1) Accreditation by the CARF is recommended, but not
required.
(A) 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 percent of the MAR.
(B) 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 percent
of the MAR.
(2) For Division purposes, General Occupational Rehabilitation
Programs, as defined in the CARF manual, are considered Work Conditioning.
(A) The first two hours of each session shall be billed
and reimbursed as one unit, using CPT Code 97545 with modifier "WC."
Each additional hour shall be billed using CPT Code 97546 with modifier
"WC." CARF accredited Programs shall add "CA" as a second modifier.
(B) Reimbursement shall be $36 per hour. Units of less
than one hour shall be prorated by 15 minute increments. A single
15 minute increment may be billed and reimbursed if greater than or
equal to eight minutes and less than 23 minutes.
(3) For Division purposes, Comprehensive Occupational
Rehabilitation Programs, as defined in the CARF manual, are considered
Work Hardening.
(A) The first two hours of each session shall be billed
and reimbursed as one unit, using CPT Code 97545 with modifier "WH."
Each additional hour shall be billed using CPT Code 97546 with modifier
"WH." CARF accredited Programs shall add "CA" as a second modifier.
(B) Reimbursement shall be $64 per hour. Units of less
than one 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.
(4) The following shall be applied for billing and
reimbursement of Outpatient Medical Rehabilitation Programs.
(A) Program shall be billed and reimbursed using CPT
Code 97799 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.
(B) Reimbursement shall be $90 per hour. Units of less
than one hour shall be prorated by 15 minute increments. A single
15 minute increment may be billed and reimbursed if greater than or
equal to eight minutes and less than 23 minutes.
(5) The following shall be applied for billing and
reimbursement of Chronic Pain Management/Interdisciplinary Pain Rehabilitation
Programs.
(A) Program shall be billed and reimbursed using CPT
Code 97799 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.
(B) Reimbursement shall be $125 per hour. Units of
less than one hour shall be prorated in 15 minute increments. A single
15 minute increment may be billed and reimbursed if greater than or
equal to eight minutes and less than 23 minutes.
(i) The following shall apply to Designated Doctor
Examinations.
(1) Designated Doctors shall perform examinations in
accordance with Labor Code §§408.004, 408.0041 and 408.151
and Division rules, and shall be billed and reimbursed as follows:
(A) Impairment caused by the compensable injury shall
be billed and reimbursed in accordance with subsection (j) of this
section, and the use of the additional modifier "W5" is the first
modifier to be applied when performed by a designated doctor;
(B) Attainment of maximum medical improvement shall
be billed and reimbursed in accordance with subsection (j) of this
section, and the use of the additional modifier "W5" is the first
modifier to be applied when performed by a designated doctor;
(C) Extent of the employee's compensable injury shall
be billed and reimbursed in accordance with subsection (k) of this
section, with the use of the additional modifier "W6";
(D) Whether the injured employee's disability is a
direct result of the work-related injury shall be billed and reimbursed
in accordance with subsection (k) of this section, with the use of
the additional modifier "W7";
(E) Ability of the employee to return to work shall
be billed and reimbursed in accordance with subsection (k) of this
section, with the use of the additional modifier "W8"; and
(F) Issues similar to those described in subparagraphs
(A) - (E) of this paragraph shall be billed and reimbursed in accordance
with subsection (k) of this section, with the use of the additional
modifier "W9."
(2) When multiple examinations under the same specific
Division order are performed concurrently under paragraph (1)(C) -
(F) of this subsection:
(A) the first examination shall be reimbursed at 100
percent of the set fee outlined in subsection (k) of this section;
(B) the second examination shall be reimbursed at 50
percent of the set fee outlined in subsection (k) of this section;
and
(C) subsequent examinations shall be reimbursed at
25 percent of the set fee outlined in subsection (k) of this section.
(j) Maximum Medical Improvement and/or Impairment Rating
(MMI/IR) examinations shall be billed and reimbursed as follows:
(1) 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:
(A) the examination;
(B) consultation with the injured employee;
(C) review of the records and films;
(D) 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,
(E) tests used to assign the IR, as outlined in the
AMA Guides to the Evaluation of Permanent Impairment (AMA Guides),
as stated in the Act and Division rules in Chapter 130 of this title
(relating to Impairment and Supplemental Income Benefits).
(2) An 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 Division rules in Chapter 130 of this title.
(A) 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
paragraph (3) of this subsection. Modifier "NM" shall be added.
(B) 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 paragraph (3) of this subsection.
(C) 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 paragraphs (3) and (4) of this subsection.
(3) The following applies for billing and reimbursement
of an MMI evaluation.
(A) An examining doctor who is the treating doctor
shall bill using CPT Code 99455 with the appropriate modifier.
(i) Reimbursement shall be the applicable established
patient office visit level associated with the examination.
Cont'd... |
