| (a) Specific provisions contained in the Labor Code
or 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 decisions regarding 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 shall 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 shall submit medical bills
in accordance with the Labor Code and division rules.
(2) 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, insurance
carriers shall treat them in accordance with Medicare and Texas Medicaid
rules. Additionally, division-specific modifiers are identified in
subsection (e) of this section. When two or more modifiers are applicable
to a single HCPCS code, indicate each modifier on the bill.
(3) A 10 percent incentive payment shall be added to
the maximum allowable reimbursement (MAR) for services outlined in §§134.220,
134.225, 134.235, 134.240, and 134.250 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.
(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 Labor Code §413.011, 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.
(e) The following division modifiers shall be used
by health care providers billing professional medical services for
correct coding, reporting, billing, and reimbursement of the procedure
codes.
(1) CA, Commission on Accreditation of Rehabilitation
Facilities (CARF) accredited programs--This modifier shall be used
when a health care provider bills for a return to work rehabilitation
program that is CARF accredited.
(2) CP, chronic pain management program--This modifier
shall be added to CPT code 97799 to indicate chronic pain management
program services were performed.
(3) FC, functional capacity--This modifier shall be
added to CPT code 97750 when a functional capacity evaluation is performed.
(4) MR, outpatient medical rehabilitation program--This
modifier shall be added to CPT code 97799 to indicate outpatient medical
rehabilitation program services were performed.
(5) MI, multiple impairment ratings--This modifier
shall be added to CPT code 99455 when the designated doctor is required
to complete multiple impairment ratings calculations.
(6) NM, not at maximum medical improvement (MMI)--This
modifier shall 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.
(7) RE, return to work (RTW) and/or evaluation of medical
care (EMC)--This modifier shall be added to CPT code 99456 when a
RTW or EMC examination is performed.
(8) SP, specialty area--This modifier shall be added
to the appropriate MMI CPT code when a specialty area is incorporated
into the MMI report.
(9) TC, technical component--This modifier shall be
added to the CPT code when the technical component of a procedure
is billed separately.
(10) VR, review report--This modifier shall be added
to CPT code 99455 to indicate that the service was the treating doctor's
review of report(s) only.
(11) V1, level of MMI for treating doctor--This modifier
shall be added to CPT code 99455 when the office visit level of service
is equal to a "minimal" level.
(12) V2, level of MMI for treating doctor--This modifier
shall be added to CPT code 99455 when the office visit level of service
is equal to "self limited or minor" level.
(13) V3, level of MMI for treating doctor--This modifier
shall be added to CPT code 99455 when the office visit level of service
is equal to "low to moderate" level.
(14) V4, level of MMI for treating doctor--This modifier
shall be added to CPT code 99455 when the office visit level of service
is equal to "moderate to high severity" level and at least 25 minutes
duration.
(15) V5, level of MMI for treating doctor--This modifier
shall be added to CPT code 99455 when the office visit level of service
is equal to "moderate to high severity" level and at least 45 minutes
duration.
(16) WC, work conditioning--This modifier shall be
added to CPT code 97545 to indicate work conditioning was performed.
(17) WH, work hardening--This modifier shall be added
to CPT code 97545 to indicate work hardening was performed.
(18) WP, whole procedure--This modifier shall be added
to the CPT code when both the professional and technical components
of a procedure are performed by a single health care provider.
(19) W1, case management for treating doctor--This
modifier shall be added to the appropriate case management billing
code activities when performed by the treating doctor.
(20) W5, designated doctor examination for impairment
or attainment of MMI--This modifier shall 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.
(21) W6, designated doctor examination for extent--This
modifier shall be added to the appropriate examination code performed
by a designated doctor when determining extent of the injured employee's
compensable injury.
(22) W7, designated doctor examination for disability--This
modifier shall 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.
(23) W8, designated doctor examination for return to
work--This modifier shall be added to the appropriate examination
code performed by a designated doctor when determining the ability
of injured employee to return to work.
(24) W9, designated doctor examination for other similar
issues--This modifier shall be added to the appropriate examination
code performed by a designated doctor when determining other similar
issues.
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