Texas Register

TITLE 28 INSURANCE
PART 2TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION
CHAPTER 134BENEFITS--GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS
SUBCHAPTER CMEDICAL FEE GUIDELINES
RULE §134.220Case Management Services
ISSUE 03/18/2016
ACTION Proposed
Preamble Texas Admin Code Rule

Case management responsibilities by the treating doctor are 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 health care provider 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 health care provider shall be $28 when a health care provider 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 health care provider shall be $50 when a health care provider 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 health care provider 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 health care provider 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 health care provider contributing to this case management action shall be $23.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on March 4, 2016

TRD-201601114

Marisa Lopez Wagley

Acting General Counsel

Texas Department of Insurance, Division of Workers' Compensation

Earliest possible date of adoption: April 17, 2016

For further information, please call: (512) 804-4703



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