| (a) Applicability of this rule is as follows:
(1) This section applies to workers' compensation specific
codes, services and programs provided in the Texas workers' compensation
system, other than:
(A) professional medical services described in §134.203
of this title (relating to Medical Fee Guideline for Professional
Services);
(B) prescription drugs or medicine;
(C) dental services;
(D) the facility services of a hospital or other health
care facility; and
(E) medical services provided through a workers' compensation
health care network certified pursuant to Insurance Code Chapter 1305,
except as provided in §134.1 of this title and Insurance Code
Chapter 1305.
(2) This section applies to workers' compensation specific
codes, services and programs provided from March 1, 2008 until September
1, 2016.
(3) For workers' compensation specific codes, services
and programs provided between August 1, 2003 and March 1, 2008, §134.202
of this title (relating to Medical Fee Guideline) applies.
(4) For workers' compensation specific codes, services
and programs provided prior to August 1, 2003, §134.201 of this
title (relating to Medical Fee Guideline for Medical Treatments and
Services Provided under the Texas Workers' Compensation Act) and §134.302
of this title (relating to Dental Fee Guideline) apply.
(5) Specific provisions contained in the Labor Code
or the Texas Department of Insurance, Division of Workers' Compensation
(Division) rules, including this chapter, shall take precedence over
any conflicting provision adopted or utilized by the Centers for Medicare
and Medicaid Services (CMS) in administering the Medicare program.
Independent Review Organization (IRO) decisions regarding medical
necessity made in accordance with Labor Code §413.031 and §133.308
of this title (relating to MDR by Independent Review Organizations),
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) Billing. Health care providers (HCPs) shall bill
their usual and customary charges using the most current Level I (CPT
codes) and Level II Healthcare Common Procedure Coding System (HCPCS)
codes. HCPs shall submit medical bills in accordance with the Labor
Code and Division rules.
(2) Modifiers. Modifying circumstance shall be identified
by use of the appropriate modifier following the appropriate Level
I (CPT codes) and Level II HCPCS codes. Where HCPCS modifiers apply,
carriers shall treat them in accordance with Medicare and Texas Medicaid
rules. Additionally, Division-specific modifiers are identified in
subsection (n) of this section. When two or more modifiers are applicable
to a single HCPCS code, indicate each modifier on the bill.
(3) Incentive Payments. A 10 percent incentive payment
shall be added to the maximum allowable reimbursement (MAR) for services
outlined in subsections (d), (e), (g), (i), (j), and (k) of this section
that are performed in designated workers' compensation underserved
areas in accordance with §134.2 of this title (relating to Incentive
Payments for Workers' Compensation Underserved Areas).
(c) When there is a negotiated or contracted amount
that complies with Labor Code §413.011, reimbursement shall be
the negotiated or contracted amount that applies to the billed services.
(d) When there is no negotiated or contracted amount
that complies with §413.011 of the Labor Code, reimbursement
shall be the least of the:
(1) MAR amount;
(2) health care provider's usual and customary charge,
unless directed by Division rule to bill a specific amount; or
(3) fair and reasonable amount consistent with the
standards of §134.1 of this title (relating to Medical Reimbursement).
(e) Case Management Responsibilities by the Treating
Doctor is as follows:
(1) Team conferences and telephone calls shall include
coordination with an interdisciplinary team.
(A) Team members shall not be employees of the treating
doctor.
(B) Team conferences and telephone calls must be outside
of an interdisciplinary program. Documentation shall include the purpose
and outcome of conferences and telephone calls, and the name and specialty
of each individual attending the team conference or engaged in a phone
call.
(2) Team conferences and telephone 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.
(3) Contact with one or more members of the interdisciplinary
team more often than once every 30 days shall be limited to the following:
(A) coordinating with the employer, employee, or an
assigned medical or vocational case manager to determine return to
work options;
(B) developing or revising a treatment plan, including
any treatment plans required by Division rules;
(C) altering or clarifying previous instructions; or
(D) coordinating the care of employees with catastrophic
or multiple injuries requiring multiple specialties.
(4) Case management services require the treating doctor
to submit documentation that identifies any HCP that contributes to
the case management activity. Case management services shall be billed
and reimbursed as follows:
(A) CPT Code 99361.
(i) Reimbursement to the treating doctor shall be $113.
Modifier "W1" shall be added.
(ii) Reimbursement to the referral HCP shall be $28
when a HCP contributes to the case management activity.
(B) CPT Code 99362.
(i) Reimbursement to the treating doctor shall be $198.
Modifier "W1" shall be added.
(ii) Reimbursement to the referral HCP shall be $50
when a HCP contributes to the case management activity.
(C) CPT Code 99371.
(i) Reimbursement to the treating doctor shall be $18.
Modifier "W1" shall be added.
(ii) Reimbursement to a referral HCP contributing to
this case management activity shall be $5.
(D) CPT Code 99372.
(i) Reimbursement to the treating doctor shall be $46.
Modifier "W1" shall be added.
(ii) Reimbursement to the referral HCP contributing
to this case management activity shall be $12.
(E) CPT Code 99373.
(i) Reimbursement to the treating doctor shall be $90.
Modifier "W1" shall be added.
(ii) Reimbursement to the referral HCP contributing
to this case management action shall be $23.
(f) To determine the MAR amount for home health services
provided through a licensed home health agency, the MAR shall be 125
percent of the published Texas Medicaid fee schedule for home health
agencies.
(g) The following applies to Functional Capacity Evaluations
(FCEs). A maximum of three FCEs for each compensable injury shall
be billed and reimbursed. FCEs ordered by the Division shall not count
toward the three FCEs allowed for each compensable injury. FCEs shall
be billed using CPT Code 97750 with modifier "FC." FCEs shall be reimbursed
in accordance with §134.203(c)(1) of this title. Reimbursement
shall be for up to a maximum of four hours for the initial test or
for a Division 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:
(1) A physical examination and neurological evaluation,
which include the following:
(A) appearance (observational and palpation);
(B) flexibility of the extremity joint or spinal region
(usually observational);
(C) posture and deformities;
(D) vascular integrity;
(E) neurological tests to detect sensory deficit;
(F) myotomal strength to detect gross motor deficit;
and
(G) reflexes to detect neurological reflex symmetry.
(2) A physical capacity evaluation of the injured area,
which includes the following:
(A) range of motion (quantitative measurements using
appropriate devices) of the injured joint or region; and
(B) strength/endurance (quantitative measures using
accurate devices) with comparison to contralateral side or normative
database. This testing may include isometric, isokinetic, or isoinertial
devices in one or more planes.
(3) Functional abilities tests, which include the following:
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