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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 insurance 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 maximum allowable reimbursement
(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 eight 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.
The agency certifies that legal counsel has
reviewed the adoption and found it to be a valid exercise of the agency's
legal authority.
Filed with the Office
of the Secretary of State on June 17, 2016
TRD-201603100 Nicholas Canaday III
General Counsel
Texas Department of Insurance, Workers' Compensation Division
Effective date: July 7, 2016
Proposal publication date: March 18, 2016
For further information, please call: (512) 804-4703
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