Part 2. TEXAS WORKERS' COMPENSATION COMMISSION

Chapter 134. BENEFITS--GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS

Subchapter A. MEDICAL POLICIES

28 TAC §134.1

The Texas Workers' Compensation Commission (the commission) proposes amendments to §134.1, concerning use of the medical fee guidelines. The amendment is proposed to make §134.1 consistent with other commission rules.

The Texas Register published text shows words proposed to be added to or deleted from the current text, and should be read to determine all proposed changes.

Since adoption of §134.1 a number of changes to the commission's fee guidelines have been adopted. As a result, the references in §134.1 to the Medical Fee Guidelines, the Pharmaceutical Fee Guidelines, and the Hospital and Ambulatory Surgical Center Fee Guidelines have become outdated. Subsections (c), (d), and (e) are proposed to be deleted to remove the outdated references. Because information regarding the applicability of the various fee guidelines is contained in the fee guidelines themselves, it is not necessary to include this information in §134.1.

In addition, it is proposed that the language "using the codes from" in subsection (b) be replaced with "in accordance with" because the fee guidelines will not necessarily contain coding information within the text of the guidelines. In subsection (f), the citation to the Workers' Compensation Act has been updated to reflect the appropriate Texas Labor Code citation.

Tom Hardy, Director of Medical Review has determined that for the first five-year period the proposed rule is in effect there will be no fiscal implications for state or local governments as a result of enforcing or administering the rule.

Local government and state government as a covered regulated entity will be impacted in the same manner as described later in this preamble for persons required to comply with the rule as proposed.

Mr. Hardy has also determined that for each year of the first five years the rule as proposed is in effect the public benefits anticipated as a result of enforcing the rule will be consistency in the rules under which all Texas worker's compensation system participants function.

There will be no anticipated economic costs to persons who are required to comply with the rule as proposed.

There will be no costs of compliance for small businesses or micro businesses. There will be no adverse economic impact on small businesses or micro-businesses. There will be no difference in the cost of compliance for small businesses or micro businesses as compared to large businesses.

Comments on the proposal must be received by 5:00 p.m., August 15, 2001. You may comment via the Internet by accessing the commission's website at www.twcc.state.tx.us and then clicking on "Proposed Rules." This medium for commenting will help you organize your comments by rule chapter. You may also comment by emailing your comments to RuleComments@Twcc.state.tx.us or by mailing or delivering your comments to Nell Cheslock at the Office of the General Counsel, Mailstop #4-D, Texas Workers' Compensation Commission, Southfield Building, 4000 South IH-35, Austin, Texas 78704-7491.

Commenters are requested to clearly identify by number the specific rule and paragraph commented upon. The commission may not be able to respond to comments that cannot be linked to a particular proposed rule. Along with your comment, it is suggested that you include the reasoning for the comment in order for commission staff to fully evaluate your recommendations.

Based upon various considerations, including comments received and the staff's or commissioners' review of those comments, or based upon the commissioners' action at the public meeting, the rule as adopted may be revised from the rule as proposed in whole or in part. Persons in support of the rule as proposed, in whole or in part, may wish to comment to that effect.

The amendment is proposed under the following statutes which are associated with the Medical Fee Guidelines: the Texas Labor Code § 402.061, which authorizes the commission to adopt rules necessary to administer the Act; the Texas Labor Code, §413.002, which requires that the commission's Medical Review Division monitor health care providers, insurance carriers and claimants to ensure compliance with commission rules; the Texas Labor Code, §413.007, which sets out information to be maintained by the commission's Medical Review Division; the Texas Labor Code, §413.011, which mandates that the commission by rule establish medical policies and guidelines; the Texas Labor Code, §413.012, which requires review and revision of the medical policies and fee guidelines at least every two years; the Texas Labor Code, §413.013, which requires the commission by rule to establish programs related to health care treatments and services for dispute resolution, monitoring, and review; the Texas Labor Code, §413.015, which requires insurance carriers to pay charges for medical services as provided in the statute and requires that the commission ensure compliance with the medical policies and fee guidelines through audit and review; the Texas Labor Code, §413.016, which provides for refund of payments made in violation of the medical policies and fee guidelines; the Texas Labor Code, §413.017, which provides a presumption of reasonableness for medical services fees which are consistent with the medical policies and fee guidelines; the Texas Labor Code, §413.019, which provides for payment of interest on delayed payments refunds or overpayments; the Texas Labor Code, §413.031, which provides a procedure for medical dispute resolution and ; the Texas Labor Code, §413.044, which provides for sanctions against designated doctors who are found to be out of compliance with the medical policies and fee guidelines. No other code, statute, or article is affected by this rule action.

§134.1.Use of the Fee Guidelines.

(a) The ground rules and the medical service standards and limitations as established by the fee guidelines shall be used to properly calculate the payments due to the health care providers.

(b) Health care providers shall bill the insurance carrier for all compensable injuries in accordance with [ using the codes from ] the fee guidelines established by the commission. The health care provider shall bill the insurance carrier for the health care treatments and services performed, and medically necessary to relieve the effects of the compensable injury and promote recovery.

(c) [ Doctors of medicine, osteopathy, dentistry, chiropractic, podiatry, optometry, psychology, and registered nurses, physical therapists, occupational therapists, imaging or radiology centers, minor emergency centers, free-standing pathology centers, durable medical equipment suppliers, and orthotic and prosthetic suppliers shall bill the insurance carrier using the medical fee guideline described in §134.200 of this title (relating to Medical Fee Guideline). ]

[ (d) Pharmacists, in settings other than a hospital, shall bill according to the Pharmaceutical Fee Guideline described in §134.501 of this title (relating to Pharmaceutical Fee Guideline).]

[ (e) Hospitals, licensed by Texas Department of Health or Texas Department of Mental Health and Mental Retardation, and ambulatory surgical centers, licensed by Texas Department of Health, shall bill according to the Hospital and Ambulatory Surgical Center Fee Guideline described in §134.400 of this title (relating to Hospital and Ambulatory Surgical Center Fee Guideline).]

[(f)] Reimbursement for services not identified in an established fee guideline shall be reimbursed at fair and reasonable rates as described in the Texas Workers' Compensation Act, §413.011 [ §8.21(b) ], until such period that specific fee guidelines are established by the commission.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on June 27, 2001.

TRD-200103676

Susan Cory

General Counsel

Texas Workers' Compensation Commission

Earliest possible date of adoption: August 12, 2001

For further information, please call: (512) 804-4287

28 TAC §§134.202 - 134.208

The Texas Workers' Compensation Commission (the commission) proposes new §§134.202 - 134.208, concerning Medical Fee Guidelines.

These new rules are proposed to comply with statutory mandates in the Texas Labor Code. Prior to the 77th Texas Legislative Session, 2001, §413.011 of the Texas Labor Code required the commission to adopt rules to establish medical policies and guidelines relating to fees charged or paid for medical services, including guidelines relating to payment of fees for specific medical treatments or services. The statute requires that guidelines for medical services fees be fair and reasonable and designed to ensure the quality of medical care and to achieve effective medical cost control. The guidelines may not provide for payment of a fee in excess of the fee charged for similar treatment of an injured individual of an equivalent standard of living and paid by that individual or by someone acting on that individual's behalf. The commission must consider the increased security of payment afforded the Texas Workers' Compensation Act (the Act) in establishing the fee guidelines. Currently, reimbursements for medical treatments and services are established by §134.201 of this title (regarding Medical Fee Guideline for Medical Treatments and Services Provided Under the Texas Workers' Compensation Act) and §134.302 of this title (regarding Dental Fee Guideline). The Medical Fee Guideline (MFG) provides maximum allowable reimbursement (MAR) amounts for care providers (HCPs) treating injured workers in Texas.

House Bill (HB) 2600, adopted during the 2001 Texas Legislative Session, amended §413.011. In addition to the previous requirements, the revised statute also requires that the commission use health care reimbursement policies and guidelines that reflect the standardized reimbursement structures found in other health care delivery systems with minimal modifications to those reimbursement methodologies as necessary to meet occupational injury requirements. To achieve standardization, the commission is to adopt the most current reimbursement methodologies, models, and values or weights used by the federal Health Care Financing Administration (HCFA), including applicable payment policies relating to coding, billing, and reporting, and may modify documentation requirements as necessary to meet the requirements of §413.053 of the Act (relating to Standards of Reporting and Billing). In determining appropriate fees, the commission must also develop conversion factors or other payment adjustment factors taking into account economic indicators in health care as well as the previous statutory requirements. The commission also must provide for reasonable fees for the evaluation and management of care. The statutory provisions explicitly state the statute does not adopt the Medicare fee schedule, and that the commission shall not adopt conversion factors or other payment adjustment factors based solely on those factors as developed by the HCFA.

Proposed new §§134.202 - 134.208 establish reimbursement for professional medical services (all health care except prescription drugs or medicines and services of health care facilities) provided on or after the effective date of the new rules. The proposed new rules revise, separate, and clarify the information and requirements of the reimbursement scheme into seven rules: applicability; professional service codes; relative value units; conversion factors; methodology; ground rules; and severability. This separation into different rules will allow separate revision and update of components of the reimbursement rules as needed. The current MFG rule contains copyrighted information that cannot be reproduced or distributed electronically. Copyrighted materials are adopted by reference in the proposed new rules. This will enable the commission to post the rules on the commission's website thus facilitating timely and less costly distribution of information to system participants and allowing the efficient and timely updating of necessary components.

The commission signed a professional services agreement with Milliman & Robertson, Inc., now Milliman USA (Milliman), a professional firm specializing in actuarial and health care services, to assist the commission in developing and implementing a new MFG. Milliman provided the commission with written reports of their findings and recommendations. The project required the following major activities:

* a market analysis of reimbursements from the 1996 MFG, commercial payers in Texas, workers' compensation systems from other states, and Medicare allowed fees in Texas, comparing the reimbursement level for corresponding services.

* recommendation of a reimbursement methodology for professional services using relative value units;

* recommendation of conversion factors to use with the relative value units to develop MAR amounts;

* evaluation of Texas regional reimbursement differences and recommendation of a basis to adjust MARs to reflect those differences;

* review of commission proposed ground rules and recommendation of any changes; and,

* recommendation of a methodology to provide reimbursement for supplies and other services, including Durable Medical Equipment (DME), Orthotics and Prosthetics, and Miscellaneous Supplies.

As part of the agreement, Milliman reviewed and analyzed the relative merits the St. Anthony's Relative Values for Physicians (RVP), and compared it with HCFA's Resource Based Relative Value System (RBRVS). Milliman recommended that the commission adopt relative value units from the RBRVS as the underlying basis for assigning payment to each professional medical service. These units are developed for the HCFA to reimburse providers treating Medicare enrollees. Milliman recommended adjustment of the relative value units by applying the HCFA Geographic Practice Cost Index (GPCI) to reflect geographic differences. Milliman also recommended using St. Anthony's RBRVS relative value units, published by Ingenix Publishing Group, to assign relative value units for professional medical services that are not valued by HCFA. Additionally, Milliman agreed with use of American Society of Anesthesiologists, Relative Value Guide for anesthesia procedures. The methodology established in proposed new §134.206 conforms to these recommendations.

Milliman drew the following conclusions as a result of the market analysis:

* commercial reimbursement rates in Texas show variations that are wider than can be explained by geographic differences, and current MFG reimbursement levels fall within this broad range;

* current MFG reimbursement levels tend to be high relative to other state workers' compensation systems, with the exception of Evaluation and Management services; and,

* current MFG MARs average approximately 130% of Medicare allowed fees.

Milliman also recommended the conversion factors established in proposed §134.205 and made recommendations with respect to ground rules in proposed §134.207.

These proposed rules adopt a methodology based on relative value units. In general, reimbursement for professional medical services is determined by:

* the relative value units which are assigned to the service by the documents adopted by reference; multiplied by

* the conversion factor assigned to convert relative value units into reimbursement payment amounts (the conversion factor is specific to the service category, as described in §134.205).

Materials to be adopted by reference in the proposed new rules are available for inspection but not duplication or sale at the commission offices, Southfield Building, 4000 South IH-35, Austin, Texas 78704-7491 and are also filed with the Texas Register . Some materials have also been published in and are available through the Federal Register (http://www.access.gpo.gov/nara/index.html) and some are available through HCFA (http://www.hcfa.gov) and may be downloaded at no cost.

Each document adopted by reference is also available for purchase from:

1. Ingenix Publishing Group, Medicode, St. Anthony's Publishing Group, P.O. Box 27116, Salt Lake City 84127, (800-999-4600), for American Medical Association's Current Procedural Terminology 2001 , Fourth Edition Revised, copyright 2000 and 2001 RBRVS, A Comprehensive Listing of RBRVS Values For all CPT and HCPCS Codes , copyright 2000.

2. American Society of Anesthesiologists, 520 North Northwest Highway, Park Ridge, Illinois, 60068-2573, 847-825-5586, for ASA's Relative Value Guide 2001 , copyright 2001.

3. National Heritage Insurance Company (NHIC), P.O. Box 200555, Austin, Texas 78720-0555, 512-514-3000, for The Texas Medicaid Fee Schedule, May 2001, Durable Medical Equipment/Medical Supplies Report J, April 2001.

4. American Dental Association, 211 East Chicago Avenue, Chicago, Illinois, 60611, 312-440-2753 for ADA's Current Dental Terminology , Third Edition, copyright 1999.

5. United States Government Printing Office, Superintendent of Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954, 202-512-1800, order online from the U. S. Government Online Bookstore at www.gpo.gov , for the following:

Volume 65 Federal Register Number 212, November 1, 2000, Addendum B "Relative Value Units and Related Information," Addendum C "Codes with Interim Relative Value Units," and Addendum E "2001 Geographic Practice Cost Indices by Medicare Carrier and Locality."

Volume 62 Federal Register Number 211, October 31. 1997, Addendum G, "Counties Included in 1998 Localities (Alphabetically by State and Locality Name Within State)"

"Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) 2001 Fee Schedule" December 19, 2000.

DESCRIPTION OF THE RULES

§134.202. Applicability.

The proposed new rules are applicable to and establish guidelines for reimbursements for "professional medical services." This includes all health care as defined in §401.011(19) of the Act other than prescription drugs or medicines, and the services of a hospital or other health care facility. Current §134.201 and §134.302 would remain in effect for treatments and services provided prior to the effective dates of the proposed new rules and current §134.201 would remain in effect for pharmaceutical services. Reimbursement is determined in accordance with the rules in effect on the date that the professional medical service was provided. Specific provisions contained in these proposed new rules would take precedence over any conflicting provisions in the documents adopted by reference.

§134.203. Professional Services Codes.

Proposed §134.203 establishes required coding for reporting, billing, and reimbursement of professional medical services. This rule adopts by reference the definitions, descriptions, and guidelines for coding from several sources. This rule achieves standardization by using these recognized coding standards.

If a document adopted by reference is revised, the rule provides for the executive director of the commission to make an administrative determination regarding use of the revised document and to establish the date by which use of the revised document is required for compliance with commission rules, decision, and orders. In determining whether to use a revised document, the executive director shall consider whether such use is consistent with applicable statutory requirements and objectives including standardization, and with commission rules in effect on the date of the revision. The executive director shall inform the commissioners of the determination, and shall inform the public by issuing a commission advisory regarding the determination and filing the determination for publication in the Texas Register .

Adoption by reference and allowing incorporation of routine revisions of coding terminology enables system participants and the commission to maintain consistency with current industry standards. Adopting documents by reference will also allow the commission to post these rules on the commission's website without necessitating the publication of any copyrighted materials. Further, website publication will facilitate timely and less costly distribution of updated information to system participants. The documents adopted by reference are widely used and readily available to system participants.

§134.204. Relative Value Units.

The RBRVS system values services according to the relative costs required to provide them, recognizing skill, practice cost, and risk. These relative value units represent national standards assigned to medical treatments and services. The relative value units reflect the relationship between the resources necessary to provide a professional medical service relative to resources necessary to provide other professional medical services. Proposed §134.204 establishes relative value units by adopting by reference the relative value units from several sources.

The RBRVS uses three components, work, practice expense, and malpractice relative values to establish the total relative value units. RBRVS relative value units are also adjusted by Geographical Practice Cost Indices to reflect geographical differences. The proposed rules also use these components and adjustments of relative values, providing the statutory adjustment factors that take health care economic indicators into account. The proposed relative value units align the basis for workers' compensation reimbursement with nationally recognized standards of relative values used in other health care delivery systems, and take into account economic indicators in health care. This proposed rule contains the same provisions regarding incorporation of revised documents.

§134.205. Conversion Factors.

Proposed §134.205 establishes the conversion factors to be applied in the calculation of reimbursement for professional medical services that are assigned relative values. The conversion factors are specific to categories of services established in the CPT plus a category of services for Physical Medicine and Rehabilitation. Conversion factors apply only to the professional medical services for which HCFA, and in certain cases, Ingenix RBRVS have assigned a relative value unit. The service categories and conversion factors are:

Evaluation & Management--$39.75

General Medicine--$53.56

Physical Medicine and Rehabilitation--$43.43

Surgery--$65.51

Anesthesiology--$30.00

Radiology--$56.06

Pathology--$55.18

Milliman reviewed current reimbursement levels for Texas insurance carriers, ten other state workers' compensation fee schedules, and Texas Medicare allowed fees. In addition, Milliman analyzed historical billed and paid Texas workers' compensation claim data provided by the commission from its medical billing database. Milliman prepared written summary reports of their analyses, including fee schedule impact, and recommended conversion factors.

The Milliman market analysis revealed: in aggregate, the current MFG generally provides a reasonable level of reimbursement relative to commercial payers; commercial payers and other states' workers' compensation fees reimburse Evaluation and Management (E/M) services at a higher level than the current MFG; and the current MFG reimburses approximately 130% of Medicare.

The conversion factors recommended by Milliman are based on analyses of the relationship between the reimbursement levels in the current MFG and the reimbursement levels of each of these other payers and consideration of the statutory requirements and objectives discussed above.

Milliman recommended conversion factors that vary by service category in order to maintain a relationship with reimbursement levels in commercial and workers' compensation payer systems (i.e., non-Medicare market).

The current MFG MARs do not correlate with RBRVS unit values; within any service category, the percentages of Medicare fees that are paid for specific services within that category vary widely. Therefore, the reimbursement of some professional medical services under the proposed rules may be significantly different than the current MFG MAR.

The conversion factor recommendations for anesthesia and pathology were developed using the comparison to Medicare allowed fees. Commercial fee schedule amounts for anesthesia were difficult to obtain, in part because anesthesia is paid on a base plus time units system. Commercial fee schedule data relating to pathology are inconsistent, reflecting both differences in reimbursement methodology and wide variations in reimbursement amounts.

These conversion factors were chosen to provide fair and reasonable compensation to health care providers, to set fees that are not in excess of the fee charged for similar treatment of an injured individual of an equivalent standard of living and paid by that individual or by someone acting on that individual's behalf, and to provide compensation that is reasonable when compared to the level paid by other states' workers' compensation systems.

§134.206. Methodology.

Proposed §134.206 describes the actual calculation process for determination of the MAR for professional medical services. The rule requires that the gross MAR be rounded to the nearest whole dollar amount. The proposed rule clarifies the actual calculation of reimbursement appropriate for professional medical services rendered. The methodology for professional medical services that have an assigned relative value unit is: (relative value units assigned to procedure adjusted by geographical variance) x (conversion factor), rounded to the nearest whole dollar amount. Examples of MAR calculations are presented for professional medical services that have assigned relative values.

The methodology for total anesthesia reimbursement (TAR) is: ((basic value + modifying factors + time units) x conversion factor), rounded to the nearest whole dollar amount.

For HCPCS Level II codes, the reimbursement level is set at 125% of the Texas Medicare allowed reimbursement. This reimbursement level is reasonable and comparable to the reimbursement levels provided by the conversion factors recommended in proposed §134.205 for professional medical services. For services and supplies lacking a Medicare reimbursement, the reimbursement level is set at 125% of the Texas Medicaid DME schedule. If the Medicare and Medicaid fee schedules do not apply, a reimbursement of 60% of usual, customary and reasonable charges is established.

For all other professional medical services, a reimbursement of 60% of usual, customary and reasonable charges is established.

The proposed rule additionally provides that the MAR for professional medical services is the least of the HCP's usual, customary and reasonable charge; any applicable contracted amount; and the MAR established by the proposed rules.

The proposed rule establishes standard methods of determining reimbursement, thereby potentially reducing the number of fee disputes related to fair and reasonable methodologies currently established by individual insurance carriers.

§134.207. Ground Rules.

Proposed §134.207 provides a workers' compensation framework appropriate for coding, reporting, billing and reimbursement by health care practitioners and insurance carriers. The rules provide standardized coding and methodologies for reimbursement, which should allow more efficient submission, administration, and reimbursement of bills. The rules also provide clarity and consistency and prevent fee disputes. In proposed §134.207 each of the service categories includes additional ground rules that modify the definitions, descriptions, and guidelines in the documents adopted by reference, to meet occupational injury and workers' compensation system requirements and needs. Ground rules duplicative of CPT are excluded.

The proposed rule also includes ground rules for professional medical services specific to the Texas workers' compensation system (e.g., impairment rating evaluations and required medical examinations). The rule also includes TWCC Modifiers applicable to certain professional medical services provided in the Texas workers' compensation system.

The coding, reporting, billing and reimbursement of professional medical services established in the proposed rules will assist the commission in tracking patterns of usual, customary and reasonable medical charges, payments and treatment protocols. Proposed §134.207 establishes documentation requirements to substantiate that professional medical services provided to an injured employee are medically appropriate and necessary. The documentation requirements in the proposed rule for professional medical services provided under the Texas Workers' Compensation Act, achieves the mandate of ensuring the quality of medical care provided to an injured employee. These are all statutory responsibilities of the commission.

Proposed §134.207, Ground Rules, utilizes health care reimbursement policies and guidelines that reflect the standardized reimbursement structures found in other health care delivery systems, with minimal modifications to those reimbursement methodologies as necessary to meet occupational injury requirements.

§134.208. Severability.

Proposed §134.208 provides that the invalidation of a section of this subchapter or its application or applications to any person or circumstance by a court of competent jurisdiction does not affect other provisions or applications of the subchapter that can be given effect without the invalidated provision or application.

Tom Hardy, Director of the Medical Review Division, has determined the following with respect to fiscal impact for the first five-year period the proposed rules are in effect.

With regard to enforcement and administration of the rule by state government, the commission will experience increased costs in some areas and decreased costs in others. Increased costs include purchase of documents that are adopted into the rules by reference, and some computer programming or software purchase costs.

Ultimately, the cost for the commission to administer and enforce these rules may decrease. The use of standardized coding, billing, and methodology should result in fewer disputes regarding medical reporting, billing and reimbursement.

* use of a standardized reimbursement structure found in other health care delivery systems should reduce the number of disputes, in part because of familiarity with other reimbursement systems, and in part because of the establishment of fair and reasonable reimbursement amounts. Establishment of appropriate conversion factors and other payment adjustors to take economic indicators in health care into account, should also reduce the number of disputes.

* use of the 2001 CPT code book should eliminate some disputes because changes in medical practice since the adoption of the current MFG will be reflected in the proposed new rules, eliminating the need for the commission to interpret the procedure and assign a reimbursement to those new procedures.

* the 2001 CPT Code book also clarifies the proper coding for some professional medical services about which there were uncertainties and disputes under the current MFG.

* updating the reimbursement amounts to reflect market analysis should also reduce disputes as to the amount of reimbursements.

* in addition, the cost and time required for the commission to update or renew the MFG should decrease because of the use of standardized components of a fee schedule.

There will be no loss or increase in revenue to the state as a result of enforcing or administering the rule.

There will be no fiscal impact on local government as a result of enforcing or administering the rule, as local governments do not have regulatory authority with respect to these rules. Local governments and state governmental entities as regulated entities will be impacted in the same manner as persons required to comply with the rules as proposed. In aggregate, medical costs should decrease for all participants in the system. Insurance carriers may or may not pass this savings on to their customers. Therefore, the commission cannot predict if local governments will experience a decrease in their premium costs if the local government's workers' compensation coverage is provided by an insurance company. Any local government that is self-insured will likely experience a cost decrease if utilization and injury experience remain unchanged. As a self-insured employer, the state is anticipated to experience the same decrease in costs using the same assumption. Using the State Office of Risk Management (SORM) data, the commission estimates that the cost savings for the state will be approximately $1 million.

Mr. Hardy has also determined that for each year of the first five years the rule as proposed is in effect the public benefits anticipated as a result of enforcing the rule will be an improved system for delivery of quality medical care with effective cost control, that will provide positive benefits to all participants in the system: injured employees, employers, insurance carriers, and health care providers.

Milliman estimates that the proposed rules will result in an aggregate reduction of approximately 5%, if applied to historical workers' compensation system claim costs. Milliman projects a similar impact on future aggregate claim costs, assuming that there is not a significant shift in the distribution of claims. A number of other factors could affect the impact including frequency of injury, severity of injury, changes in the practice of medicine for injured workers in Texas, distribution of services provided, current billing practices, and random fluctuations. As discussed above, the differential between the current MFG MAR and the proposed MAR varies from service to service even within a category of services because of the adjustments made to the current MFG relative value unit MARs. Use of standardized coding, reporting, billing, and reimbursement methodologies in the rules as proposed should decrease fee disputes within the workers' compensation system.

The establishment of fair and reasonable reimbursements provides quality health care to injured workers. The proposed rules should improve access to care for injured workers because reimbursements under the proposed rules are more closely related to the resources required to provide the services. A decrease in medical costs may increase the number of employers who elect workers' compensation coverage, and injured workers will benefit from that coverage.

Milliman estimates the impact by category as follows:

Evaluation & Management: +10%

Medicine: +7%

Physical Medicine and Rehabilitation: -14%

Surgery: -5%

nesthesiology : -25%

Radiology: -13%

Pathology: -23%

The increase or decrease in the reimbursement for any procedure within a category can vary significantly, since the current MFG MARs do not correlate with RBRVS unit values. Some health care practitioners will receive more reimbursement than under the current MFG, while others will receive less, depending on the types of professional medical services they typically provide to patients.

Health care practitioners will benefit from the use of standardized and current methodologies, models, and value units, and use of standardized reporting, billing, and coding requirements. Clarity in the rules and reduction in the number of disputes should also benefit health care practitioners.

Insurance carriers will likewise benefit from use of standardized and current methodologies, models, and value units, and use of standardized reporting, billing, and coding requirements. Insurance carriers should also benefit from the reduction in medical costs that results from adoption of these rules. Clarity in the rules and reduction in the number of disputes should also benefit insurance carriers.

Employers will similarly benefit from the reduction in costs and disputes, which may be favorably reflected in the cost to employers to provide workers' compensation coverage.

There will be some anticipated economic costs to persons required to comply with the rules as proposed. There will be no economic cost to injured workers, as these proposed rules do not impose any requirements on injured workers.

Health care practitioners will experience some increased costs in some areas and decreased costs in others. Increased costs include purchase of documents that are adopted into the rules by reference, and some computer programming or software purchase costs. Those who are already using those documents and methodologies will not experience these same increased costs. Decreased costs will result from the fact that the number of disputes should decrease for the reasons describes above.

Insurance carriers should experience the same increased costs in some areas and decreased costs in others. Increased costs include purchase of documents that are adopted into the rules by reference, and some computer programming or software purchase costs. Again, those who are already using those documents and methodologies will not experience these same increased costs. Decreased costs will result from the fact that the number of disputes should decrease for the reasons describes above.

There will be no adverse economic impact on small businesses or on micro-businesses as a result of the proposed new rules. Health care practitioners and insurance carriers who perform only a small amount of work in the workers' compensation system can comply with these rules without incurring purchasing or programming costs. Many health care practitioners and insurance carrier already use the standardized items adopted in these proposed rules, and cost savings explained previously should offset any increased costs.

There will be only a proportionate difference in the cost of compliance for small businesses and micro-businesses as compared to the largest businesses, including state and local government entities. The same basic processes and procedures apply, regardless of the size or volume of the business. The business size cost difference will be in direct proportion to the volume of business that falls under the purview of these proposed rules. Any increases in costs is expected to be offset by cost savings and time savings through the use of a standardized form and streamlined process, resulting in no adverse economic impact.

Comments on the proposal must be received by 5:00 p.m., August 15, 2001. You may comment via the Internet by accessing the commission's website at www.twcc.state.tx.us and then clicking on "Proposed Rules." This medium for commenting will help you organize your comments. You may also comment by e-mailing your comments to RuleComments@twcc.state.tx.us or by mailing or delivering your comments to Nell Cheslock at the Office of the General Counsel, Mailstop #4-D, Texas Workers' Compensation Commission, Southfield Building, 4000 South IH-35, Austin, Texas 78704-7491.

Commenters are requested to clearly identify by number the specific rule and paragraph commented upon. The commission may not be able to respond to comments that cannot be linked to a particular proposed rule. Along with your comment, it is suggested that you include the reasoning for the comment in order for commission staff to fully evaluate your recommendations.

Based upon various considerations, including comments received and the staff's or commissioners' review of those comments, or based upon the commissioners' action at the public meeting, the rule as adopted may be revised from the rule as proposed in whole or in part. Persons in support of the rule as proposed, in whole or in part, may wish to comment to that effect.

A public hearing on this proposal will be held on August 15, 2001 at the Austin central office of the commission (Southfield Building, 4000 South IH-35, Austin, Texas). Those persons interested in attending the public hearing should contact the Commission's Office of Executive Communication at (512) 804-4430 to confirm the date, time, and location of the public hearing for this proposal. The public hearing schedule will also be available on the commission's website at www.twcc.state.tx.us .

The new rules are proposed under the Texas Labor Code §402.061, which authorizes the commission to adopt rules necessary to administer the Act; the Texas Labor Code, §413.002, which requires the commission's Medical Review Division monitor health care providers, insurance carriers and claimants to ensure compliance with commission rules; the Texas Labor Code, §413.007, which sets out information to be maintained by the commission's Medical Review Division; the Texas Labor Code §413.011, which mandates that the commission by rule establish medical policies and guidelines; the Texas Labor Code, §413.012, which requires review and revision of the medical policies and fee guidelines at least every two years; the Texas Labor Code, §413.013, which requires the commission by rule to establish programs related to health care treatments and services for dispute resolution, monitoring, and review; the Texas Labor Code, §413.015, which requires insurance carriers to pay charges for medical services as provided in the statute and requires that the commission ensure compliance with the medical policies and fee guidelines through audit and review; the Texas Labor Code, §413.016, which provides for refund of payments made in violation of the medical policies and fee guidelines; the Texas Labor Code, §413.017, which provides a presumption of reasonableness for medical services fees which are consistent with the medical policies and fee guidelines; the Texas Labor Code, §413.019, which provides for payment of interest on delayed payments refunds or overpayments; and the Texas Labor Code, §413.031, which provides a procedure for medical dispute resolution; the Texas Labor Code, §413.044, which provides for sanctions against designated doctors who are found to be out of compliance with the medical policies and fee guidelines.

The proposed new rules affect the following statutes which are associated with the Medical Fee Guidelines: the Texas Labor Code §402.061, which authorizes the commission to adopt rules necessary to administer the Act; the Texas Labor Code, §413.002, which requires that the commission's Medical Review Division monitor health care providers, insurance carriers and claimants to ensure compliance with commission rules; the Texas Labor Code, §413.007, which sets out information to be maintained by the commission's Medical Review Division; the Texas Labor Code, §413.011, which mandates that the commission by rule establish medical policies and guidelines; the Texas Labor Code, §413.012, which requires review and revision of the medical policies and fee guidelines at least every two years; the Texas Labor Code, §413.013, which requires the commission by rule to establish programs related to health care treatments and services for dispute resolution, monitoring, and review; the Texas Labor Code, §413.014, which requires express preauthorization by the insurance carrier for health care treatments and services; the Texas Labor Code, §413.015, which requires insurance carriers to pay charges for medical services as provided in the statute and requires that the commission ensure compliance with the medical policies and fee guidelines through audit and review; the Texas Labor Code, §413.016, which provides for refund of payments made in violation of the medical policies and fee guidelines; the Texas Labor Code, §413.017, which provides a presumption of reasonableness for medical services fees which are consistent with the medical policies and fee guidelines; the Texas Labor Code, §413.019, which provides for payment of interest on delayed payments refunds or overpayments; and the Texas Labor Code, §413.031, which provides a procedure for medical dispute resolution; the Texas Labor Code, §413.044, which provides for sanctions against designated doctors who are found to be out of compliance with the medical policies and fee guidelines.

§134.202.Applicability.

(a) Sections 134.202 - 134.208 of this title apply to professional medical services (health care other than prescription drugs or medicine, and the services of a hospital or other health care facility). Reimbursement shall be determined in accordance with the rules in effect on the date the professional medical service was provided.

(1) For professional medical services provided on or after the effective date of this rule, §§134.202 - 134.208 of this title shall be applicable.

(2) For professional medical services provided prior to the effective date of this rule, §134.201 and §134.302 of this title shall be applicable.

(3) For all prescription drugs or medicines provided, the terms of §134.201 of this title shall be applicable until such time as the Commission adopts a pharmacy services guideline.

(b) Specific provisions contained in §§134.203 - 134.208 of this title shall take precedence over any conflicting provision in any document adopted by reference.

(c) If a section of this subchapter is declared invalid in a final judgment that is not subject to appeal, or is suspended by order of the court which is given immediate effect, §134.201 and §134.302 of this title shall remain in effect to the extent necessary.

§134.203.Professional Services Codes.

(a) The Texas Workers' Compensation Commission (the commission) adopts herein, by reference the following for use in coding professional medical services:

(1) American Medical Association's Current Procedural Terminology 2001, Fourth Edition Revised, copyright 2000, Current Procedural Terminology is also known as the Health Care Financing Administration Common Procedure Coding System (HCPCS) Level I codes.

(2) HCPCS Level II codes, limited to A, E, J, K, and L codes and the related modifiers. The J codes are published in Addendum B "Relative Value Units and Related Information," of Volume 65 Federal Register Number 212, November 1, 2000. The A, E, K and L codes are available from the Health Care Financing Administration's "Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) 2001 Fee Schedule" December 19, 2000.

(3) American Dental Association's Current Dental Terminology , Third Edition, copyright 1999.

(b) The definitions, descriptions and guidelines found in the documents adopted by reference in subsection (a) of this section shall govern the coding, reporting, billing and reimbursement of professional medical services with any additions or exceptions provided in §134.207 of this title (relating to Ground Rules).

(c) Whenever a document adopted by reference in this section is revised, the executive director of the commission shall make an administrative determination regarding use of the revised document and shall establish the date by which use of the revised document is required for compliance with commission rules, decision, and orders. In determining whether to incorporate a revised document, the executive director shall consider whether use is consistent with applicable statutory requirements and objectives including standardization, and with commission rules in effect on the date of the revision. The executive director shall inform the commissioners of the determination, and shall inform the public by issuing a commission advisory regarding the determination and by filing the determination for publication in the Texas Register .

(d) Information on how to purchase or obtain copies of the most current referenced documents is available by contacting the commission's Publications Department or accessing the commission's website: www.twcc.state.tx.us. .

§134.204.Relative Value Units.

(a) The Texas Workers' Compensation Commission (the commission) adopts herein, by reference the following for use in determining the total relative value units of professional medical services except as otherwise provided in §§134.202 - 134.208 of this title:

(1) The following portions of the Health Care Financing Administration's (HCFA) 2001 Medicare Resource-Based Relative Value System:

(A) Volume 65 Federal Register Number 212, November 1, 2000:

(i) Addendum B "Relative Value Units and Related Information;"

(i) Addendum C "Codes with Interim Relative Value Units;"

(iii) Addendum E "2001 Geographic Practice Cost Indices by Medicare Carrier and Locality."

(B) Volume 62 Federal Register Number 211, October 31, 1997, Addendum G, "Counties Included in 1998 Localities (Alphabetically by State and Locality Name Within State)"

(2) The American Society of Anesthesiologists, Relative Value Guide 2001, copyright 2001, for those anesthesia codes without an established HCFA relative value.

(3) The Ingenix 2001 RBRVS, A Comprehensive Listing of RBRVS Values For all CPT and HCPCS Codes , copyright 2000, for procedure codes without an established HCFA relative value.

(4) The Texas Medicaid Fee Schedule, May 2001, Durable Medical Equipment/Medical Supplies Report J.

(b) Whenever a document adopted by reference in this section is revised, the executive director of the commission shall make an administrative determination regarding use of the revised document and shall establish the date by which use of the revised document is required for compliance with commission rules, decision, and orders. In determining whether to incorporate a revised document, the executive director shall consider whether use is consistent with applicable statutory requirements and objectives including standardization, and with commission rules in effect on the date of the revision. The executive director shall inform the commissioners of the determination, and shall inform the public by issuing a commission advisory regarding the determination and by filing the determination for publication in the Texas Register .

(c) Information on how to purchase or obtain copies of the most current referenced documents is available by contacting the commission's Publications Department or accessing the commission's website: www.twcc.state.tx.us. .

§134.205.Conversion Factors.

(a) The conversion factors shall be utilized as described in §134.206 of this title (relating to Methodology).

(b) The conversion factors for service categories are as follows:

(1) Evaluation & Management--$39.75

(2) General Medicine--$53.56

(3) Physical Medicine and Rehabilitation--$43.43

(4) Surgery--$65.51

(5) Anesthesiology--$30.00

(6) Radiology--$56.06

(7) Pathology--$55.18

§134.206.Methodology.

(a) Maximum Allowable Reimbursement (MAR) for codes with an assigned relative value shall be determined by multiplying the total relative value units (RVU) by the applicable conversion factor (CF) and then rounding to the nearest whole dollar. For instructions on the use of modifiers, refer to the documents adopted by reference in §134.203 of this title (relating to Professional Services Codes) and to §134.207 of this title (relating to Ground Rules).

(1) To determine the Total RVU:

(A) Locate the applicable RVUs for a Current Procedural Terminology (CPT) code, in accordance with §134.204 of this title (relating to Relative Value Units).

(i) Identify the appropriate CPT code in the Health Care Financing Administration (HCFA) Resource Based Relative Value System (RBRVS) list for the RVU, or in the Ingenix 2001 list if a HCFA RVU is not established.

(ii) Identify the RVUs by using the following columns:

(I) Work RVU Column

(II) Transitioned Non-facility Practice Expense (PE) RVU Column

(III) Malpractice (MP) RVU Column

(B) Refer to HCFA Addendum E and Addendum G adopted in §134.204(a) of this title (relating to Relative Value Units) to determine the applicable Geographical Practice Cost Indices (GPCIs) and counties.

(C) Apply the following formula for Total RVUs: ((Work RVU x Work GCPI) + (PE RVU x PE GCPI) + (MP RVU x MP GCPI)) = Total RVUs

(2) To determine the applicable CF refer to §134.205 of this title (relating to Conversion Factors).

(3) Apply the following formula to determine a MAR: (Total Relative Value Units x CF) Rounded to the nearest whole dollar = MAR. Example: CPT: RVU x CF = Gross MAR = MAR; 99XXX: 1.32 x $40.12 = $52.96 = $53.00; 99XX1: 1.38 x $40.12 = $55.37 = $55.00; 99XX2: 2.00 x $27.75 = $55.50 = $56.00

(4) The following applies in determining MARs:

(A) For surgical global period follow-up days (FUD), use the global days column from the HCFA RBRVS list, or use the FUD column from the Ingenix 2001 list if the procedure is not listed in the HCFA RBRVS list; and

(B) HCFA RBRVS columns not referenced in this rule do not apply.

(b) MARs for Texas Workers' Compensation Commission (the commission) specific codes, services and programs (e.g. Functional Capacity Evaluations, Impairment Rating evaluations, Work Hardening, Work Conditioning, etc.) are designated in §134.207 of this title (relating to Ground Rules). Subsection (a) of this section does not apply to these codes.

(c) MARs for anesthesia services shall be determined as follows:

(1) The Total Anesthesia Reimbursement (TAR) for each procedure is the sum of the basic value, any modifying factors (i.e., physical status modifiers and qualifying circumstances), and the time units, multiplied by the CF and then rounded to the nearest whole dollar. TAR = ((basic value + modifying factors + time units) x CF) rounded to the nearest whole dollar.

(A) Basic value: The relative value of all usual anesthesia services.

(B) Time units: The anesthesia time units shall be calculated in fifteen minute intervals, or portion thereof, with each interval equal to one time unit.

(C) Modifying Factors:

(i) Physical Status Modifiers

(ii) Qualifying Circumstances

(D) Conversion Factor: To determine the applicable CF refer to §134.205 of this title (relating to Conversion Factors).

(2) Modes of Anesthesia Practice and Reimbursement

(A) Anesthesiologist or Certified Registered Nurse Anesthetist (CRNA): When an anesthesiologist or CRNA is conducting a total and individual anesthesia service, the anesthesiologist/CRNA shall bill and be reimbursed at 100% of the TAR.

(B) Concurrent Supervision: When an anesthesiologist is directing the services of a CRNA, including pre- and post-operative evaluation and care, but is not personally administering the anesthesia, the CRNA shall not bill or be reimbursed. The following shall apply for the anesthesiologist's reimbursement:

(i) One directed anesthetic procedure 100% of the TAR

(ii) Two directed anesthetic procedures 90% of the TAR for each procedure

(iii) Three directed anesthetic procedures 80% of the TAR for each procedure

(iv) Four directed anesthetic procedures 70% of the TAR for each procedure.

(d) Reimbursement for HCPCS Level II codes A, E, J, K, and L shall be:

(1) 125% of the published Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule;

(2) 125% of the published Texas Medicaid Fee Schedule Durable Medical Equipment/Medical Supplies Report J, for HCPCS without a published Medicare rate; or,

(3) as stated in subsection (f) of this section if paragraphs (1) and (2) of this subsection do not apply.

(e) Reimbursement of dental treatments and services shall be based on the use of CDT codes, and shall be reimbursed 60% of the health care provider's usual, customary and reasonable charge.

(f) Reimbursement of any CPT or HCPCS codes not addressed in subsections (a) - (e) of this section shall be 60% of the health care provider's usual, customary and reasonable charge.

(g) In all cases, reimbursement shall be the least of the:

(1) commission's fair and reasonable amount as established by this rule;

(2) health care provider's usual, customary and reasonable charge; or,

(3) health care provider's negotiated and/or contracted amount.

§134.207.Ground Rules.

(a) General Instructions. All participants coding, reporting, billing and reimbursing in the workers' compensation system shall be responsible for correctly applying the ground rules contained in this section, in addition to the guidelines in the documents adopted by reference in §134.203 of this title (relating to Professional Services Codes).

(1) Application of Ground Rules. Ground rules, specific to a particular group of codes, provide definitions and instructions necessary to correctly interpret, report, and reimburse the professional medical services contained in that group of codes.

(2) Billing. Health care providers (HCPs) shall bill their usual, customary, and reasonable charges. HCPs shall submit medical bills in accordance with the Texas Workers' Compensation Act (the Act) and commission rules Chapter 133 of this title. Disputes regarding reimbursement shall be resolved in accordance with the Act and commission rules and procedures.

(3) Scope of Practice. This section does not supersede the scope of practice limitations of the licensed HCP.

(A) The HCP shall comply with the ground rules outlined in the pertinent section for the procedure(s) performed. Any HCP, regardless of type of licensure, may use any section containing the procedure(s) performed as long as the procedure(s) is within the HCP's scope of practice or license as defined by Texas law.

(B) The maximum allowable reimbursement (MAR) only applies when a licensed HCP is performing those services within the scope of practice for which the HCP is licensed, or when a non-licensed individual is rendering care under the supervision of a licensed HCP.

(C) For the purposes of these guidelines, supervision is as defined in the HCP's licensing or practice act.

(4) Modifiers. Modifying circumstance shall be identified by use of the appropriate modifier, including the hyphen, following the appropriate code. In addition to the documents adopted by reference in §134.203 of this title, Texas Workers' Compensation Commission (TWCC) specific modifiers are identified in subsection (l) of this section. When two modifiers are applicable to a single code, indicate each modifier, including the hyphen, on the bill. When using AMA CPT modifiers, provide documentation of procedure.

(5) Documentation of Procedure (DOP). When DOP is required, the value of the procedure shall be determined by written documentation attached to or included in the bill. The required documentation may vary based on the complexity of the procedure. No additional reimbursement shall be allowed for the submission of documentation to substantiate the procedure or service. DOP shall include pertinent information about the procedure, including:

(A) description of procedure provided;

(B) nature, extent, and need (e.g., complexity of symptoms, diagnosis, and rationale) for the service or procedure;

(C) time required to perform the service or procedure (include start and end times);

(D) skill level necessary for performance of the service or procedure;

(E) equipment used (if applicable); and

(F) other information as necessary.

(6) Materials Supplied by the HCP. When the cumulative total charge for the provision of supplies and materials that are not usually included in the office visit exceeds $10 for a date of service, the supplies and materials may be billed separately using HCPCS codes. If no HCPCS code is available, then the "Supplies and materials..." CPT code shall be used and a description shall be included. DOP for supplies is also required for any single supply item that is billed at $50 or greater.

(A) Supplies that are usually included in the office visit include, but are not limited to:

(i) injection or debridement trays;

(ii) needles;

(iii) steristrips;

(iv) syringes;

(v) eye/ear trays;

(vi) drapes;

(vii) sterile gloves;

(viii) applied eye wash or drops;

(ix) creams (massage);

(x) fluorescein;

(xi) ultrasound pads and gel;

(xii) tissues;

(xiii) urine collection kits;

(xiv) gauze;

(xv) cotton balls/fluff;

(xvi) sterile water;

(xvii) head sheet;

(xviii) aspiration trays;

(xix) tape for dressing; and,

(xx) bandaids and dressings for simple wound occlusion.

(B) Supplies that are not usually included in the office visit include, but are not limited to:

(i) sterile trays for laceration repair and more complex surgeries;

(ii) applied dressings beyond simple wound occlusion;

(iii) taping supplies for sprains;

(iv) iontophoresis electrodes;

(v) casting and strapping materials;

(vi) reusable patient specific electrodes; and,

(vii) dispensed items (hot/cold packs, canes, braces, slings, ace wraps, TENS electrodes, crutches, splints, back supports, dressings, etc).

(7) Preauthorization of Specific Treatments/Services. The HCP is required to obtain preauthorization from the insurance carrier prior to rendering certain services or procedures. To determine whether a treatment or service requires reauthorization, the HCP shall refer to the act and commission rule(s) regarding preauthorization.

(b) Evaluation and Management (E/M) Ground Rules. HCPs billing professional medical services in the Evaluation and Management section of the AMA CPT shall utilize the following for correct coding, reporting, billing, and reimbursement of the E/M CPT codes.

(1) E/M services initiated by the referral doctor shall be billed and reimbursed using office visit codes, not consultation codes.

(2) E/M services provided by a Physician Assistant (PA) or Nurse Practitioner (NP), under the supervision of a doctor, shall be billed by the doctor using the appropriate E/M code with either modifier "-PA" or "-NP." Reimbursement shall be 80% of the MAR.

(3) Neonatal Intensive Care shall only be billed and reimbursed if the documented condition of the infant is directly related to the consequences of the injured employee's compensable injury. Neonatal intensive care shall be assessed on a case-by-case basis and appropriate documentation shall be provided to support level(s) of service rendered. Neonatal intensive care shall occur in a Neonatal Intensive Care Unit (NICU) and shall be billed and reimbursed once per day per patient. DOP is required.

(4) Nursing Facility Services shall only be billed and reimbursed if the documented condition is directly related to or is the consequence of the compensable injury. Nursing facility services shall be assessed on a case-by-case basis. DOP is required.

(5) Domiciliary, Rest Home, Boarding Home, and Custodial Care services shall only be billed and reimbursed if the documented condition is directly related to or is the consequence of the compensable injury. Such services shall be assessed on a case-by-case basis. DOP is required.

(6) Home Services shall only be billed and reimbursed if the documented condition is directly related to or is the consequence of the compensable injury. Such services shall be assessed on a case-by-case basis. DOP is required.

(A) E/M services provided in a private residence by a doctor shall be billed and reimbursed using the "New Patient Home Services" and "Established Patient Home Services" CPT codes.

(B) Home health services provided by a home health agency shall be billed and reimbursed using the "Unlisted special service, procedure, or report" CPT code with one of the following modifiers:

(i) "-H1," for home health services provided by a Registered Nurse (RN).

(ii) "-H2," for home health services provided by a Licensed Vocational Nurse (LVN).

(iii) "-H3," for home health services provided by a Certified Nurse Assistant (CNA).

(iv) "-H4," for home health services provided by an Occupational Therapist, Physical Therapist, Speech Therapist, or other HCP, if a specific CPT code is not available for the service provided (otherwise, the appropriate CPT code(s) which describes the service provided should be used).

(v) "-H5," for home health services rendered by a Home Health Aide.

(7) Case Management is the responsibility of the treating doctor and includes the direct health care of the patient, coordination and control of access to health care, and initiation and/or supervision of other health care services needed by the injured employee.

(A) Case management services may include team conferences and telephone calls. For reimbursement, these services shall be initiated and/or coordinated by the treating doctor or another HCP (with approval from the treating doctor). Only the initiating HCP shall bill and be reimbursed for team conferences and telephone calls. DOP is required.

(i) Team conferences shall include coordination with an interdisciplinary team (outside of an interdisciplinary program) to assist in the development of treatment plans and coordinate activities of patient care.

(ii) Telephone calls shall be to the patient or other HCPs for consultation, medical management, or coordination of medical management.

(B) Any counseling and/or coordination of care involving team conferences or telephone calls (when provided as a part of or a result of the patient encounter) that occurs the same day as a patient encounter, is considered to be part of the E/M service for that session and shall not be billed or reimbursed separately.

(8) Preventive Medicine Services are not reimbursed as part of the Texas Workers' Compensation system.

(9) Newborn Care services shall only be billed and reimbursed if the treatment rendered is directly related to the injured employee's compensable injury. Newborn care shall be assessed on a case-by-case basis. DOP is required.

(10) Telemedicine is the method of delivering medical care and information over distance using computer-based telecommunications networks. Only E/M services provided by interactive modes of telemedicine (i.e., interactive video teleconferencing) shall be reimbursed. Interactive video teleconferencing refers to live, two-way video connections between two or more HCPs and the injured employee. All HCPs participating, and whose presence is required, in the video teleconferencing shall be reimbursed. The HCPs shall use the appropriate E/M CPT code with modifier "-TM," DOP is required. For reimbursement, the telemedicine service must be necessary to:

(A) the injured employee because of limited access to HCPs; or,

(B) a HCP because of limited access to other HCPs (i.e., specialists).

(c) General Medicine Ground Rules. HCPs billing professional medical services in the Medicine section of the AMA CPT shall utilize the following for correct coding, reporting, billing, and reimbursement of the Medicine CPT codes.

(1) Osteopathic Manipulation. When manipulation is provided by a Doctor of Osteopathy, Osteopathic Manipulative Treatment CPT codes shall be billed and reimbursed. If significant separately identifiable E/M services, above and beyond the usual pre-service and post-service work associated with the procedure, are provided, the HCP shall bill using the appropriate E/M CPT code with CPT modifier "-25," and DOP is required.

(2) Chiropractic Manipulation. When manipulation is provided by a Doctor of Chiropractic, Chiropractic Manipulative Treatment CPT codes shall be billed and reimbursed. If significant separately identifiable E/M services, above and beyond the usual pre-service and post-service work associated with the procedure, are provided, the HCP shall bill using the appropriate E/M CPT code with CPT modifier "-25," and DOP is required.

(3) Nerve Studies. The following provisions apply to Nerve Studies.

(A) CPT codes relating to nerve studies shall be billed and reimbursed using the CPT code for the appropriate study with one of the following modifiers:

(i) WP: This modifier shall be used if performing both the technical and professional components of the study.

(ii) -26: This modifier shall be used if performing only the professional component of the study. The professional component reimbursement shall be 30% of the MAR.

(iii) -TC: This modifier shall be used if performing only the technical component of the study. The technical component reimbursement shall be 70% of the MAR.

(B) Surface electromyography (EMG) studies shall be billed and reimbursed using the "Unlisted physical medicine/rehabilitation service or procedure" CPT code with modifier "-EM" added.

(4) Conscious Sedation. Doctors other than anesthesiologists or nurse anesthetists shall bill and be reimbursed for conscious sedation CPT codes.

(A) Conscious Sedation (with or without analgesia) CPT codes shall be billed and reimbursed when administered by a doctor also performing a simultaneous procedure.

(B) If Conscious Sedation is administered by a HCP, other than the doctor performing the procedure, then the HCP shall apply the ground rules as stated within subsection (f) of this section.

(d) Physical Medicine and Rehabilitation. HCPs billing professional medical services in the Physical Medicine and Rehabilitation subsection of the AMA CPT shall utilize the following for correct coding, reporting, billing, and reimbursement of the Physical Medicine and Rehabilitation CPT codes.

(1) Modalities and Therapeutic Procedures (Physical Medicine). The following provisions apply to physical medicine services.

(A) Physical medicine treatment performed on the same day as an initial evaluation shall be billed and reimbursed separately.

(B) Range of motion measurements and muscle testing are included in re-evaluations performed by the physical or occupational therapist and shall not be billed or reimbursed separately. Re-evaluation of the patient by the HCP can occur for any of the following reasons:

(i) a definitive change in the patient's condition;

(ii) failure to respond to treatment;

(iii) attainment of MMI; or

(iv) need for an extensive evaluation of the patient which is over and above what would be routinely provided at a therapy session.

(C) The treating doctor shall re-examine the patient as appropriate, but not less than once a month, while physical medicine treatment is being provided by the HCP.

(D) A physical medicine session is defined as any combination of up to three different physical medicine CPT codes and up to one and one-half hours of physical medicine CPT codes with time units.

(i) Multiple uses of the same CPT code count as one of the three physical medicine CPT codes per session limit.

(ii) Two sessions are allowed per day for the first week of the injury. Thereafter, only one session per day is allowed.

(iii) Time spent on Modalities with no time units does not apply toward the one and one-half hour per session time limit.

(iv) The maximum amount of time to be billed or reimbursed for physical medicine CPT codes with time units is one and one-half hours per session. Time shall be measured by billing increments.

(v) For reimbursement, the Multiple Procedure Rule found in subsection (e) of this section shall be applied to the three different physical medicine CPT codes used in each session.

(E) Therapeutic Procedures require the HCP to maintain direct patient contact during provision of the procedure. If any of the Therapeutic Procedures are performed with two or more patients then the "Therapeutic procedure, group" CPT code shall be billed rather than the code for the specific type of therapy.

(F) The exclusive use of Modalities is limited to a maximum of one week. DOP is required to substantiate the need for continued use of only these modalities.

(G) The use of Modalities in conjunction with therapeutic and other procedures shall be as described in the commission treatment guidelines. DOP is required to substantiate the need to provide treatment that is not contained in the commission treatment guidelines.

(H) Sterile whirlpool shall be billed using the "whirlpool" modality CPT code with modifier "-SW" and shall be reimbursed at $40.00. This type of treatment shall be prescribed by the doctor. There shall be no additional reimbursement for sterilizing the whirlpool or for supplies for the sterilization. DOP is required.

(I) Patient education is billed for a group setting using the "Physician educational services rendered to patients in a group setting" CPT code. If the patient education is provided in a one-on-one setting, bill using the same CPT code with modifier "-OP," DOP is required.

(J) Required or requested documentation for any physical medicine CPT code with time units shall include start and end times.

(K) Specific physical medicine services shall be billed as follows.

(i) The following services shall be billed using the "Unlisted modality" CPT code and the appropriate modifier as indicated.

(I) Continuous Passive Motion--Modifier "-CM"

(II) Fluidotherapy--Modifier "-FT"

(III) HE-NE Laser--Modifier "-HE"

(ii) The following services shall be billed using the "Unlisted therapeutic procedure" CPT code and the appropriate modifier as indicated.

(I) Autotraction--Modifier "-AT"

(II) Dressing changes--Modifier "-DC"

(III) Taping to stabilize or align joint--Modifier "-EC"

(IV) Simultaneous Electrical Stimulation/Ultrasound--Modifier "-EU"

(V) Muscle Energy Technique--Modifier "-ME"

(VI) Phonophoresis--Modifier "-PH"

(VII) Positional Release--Modifier "-PO"

(VIII) Spray and Stretch--Modifier "-SS"

(IX) TENS application for trial basis (includes supplies/training)--Modifier "-TN"

(X) Tilt table (standing frame)--Modifier "-TT"

(XI) Vertebral Axial Decompression (Vax-D)--Modifier "-VX"

(iii) External compression/taping to reduce or control edema and swelling shall be billed using the "vasopneumatic devices" modality code. External compression/taping to provide support or protection and limit motion in acute trauma and chronic circulatory conditions or to provide stabilization and joint alignment shall be billed using the "Unlisted therapeutic procedure" CPT code with modifier "-EC."

(iv) Phonophoresis supplies shall be billed using CPT code 99070 and shall be reimbursed at $7.00; iontophoresis supplies shall be billed using CPT code 99070 and shall be reimbursed at $15.00. Phonophoresis and iontophoresis shall not be reimbursed for the same area on the same day.

(L) An injury resulting in physical medicine treatment to more than one body area or region shall be substantiated by the appropriate diagnosis for the CPT codes. The following body areas are recognized for the provision of physical medicine (billing may be by region, if present, or by area):

(i) Head

(ii) Lower extremity (which is divided into two regions):

(I) Hip/Knee

(II) Ankle/Foot

(iii) Upper extremity (which is divided into two regions):

(I) Shoulder/Elbow

(II) Wrist/Hand

(iv) Trunk (Including rib cage, and abdomen)

(v) Spine (which is divided into four regions):

(I) Cervical spine

(II) Thoracic spine

(III) Lumbar spine

(IV) Sacral spine

(2) Tests and Measurements. The following provisions apply to Tests and Measurements services.

(A) Tests and Measurements CPT codes require a report of the results, and no additional reimbursement shall be allowed for this report.

(B) Job site visit/assessment shall be billed using the "Unlisted physical medicine/rehabilitation service or procedure" CPT code with modifier "-JA". A report is required and shall not be reimbursed separately. Job site visit/assessments shall be reimbursed at $25.00 per 15 minutes.

(C) A maximum of three Functional Capacity Evaluations (FCEs) for each compensable injury shall be billed and reimbursed. FCEs shall be billed using the "Physical performance test or measurement..." CPT code with modifier "-FC." FCEs shall be reimbursed at $25 per 15-minute increment up to a maximum of five hours ($500) for the first test and a maximum of two hours ($200) for a second and/or third test. A summary report for each FCE is required and shall not be billed or reimbursed separately. Required documentation includes the start and end time for the FCE. FCEs shall include the following elements:

(i) A physical examination and neurological evaluation, which include the following:

(I) appearance (observational and palpation)

(II) flexibility of the extremity joint or spinal region (usually observational)

(III) posture and deformities;

(IV) vascular integrity;

(V) neurological tests to detect sensory deficit;

(VI) myotomal strength to detect gross motor deficit; and

(VII) reflexes to detect neurological reflex symmetry.

(ii) A physical capacity evaluation of the injured area, which includes the following:

(I) range of motion (quantitative measurements using appropriate devices) of the injured joint or region; and

(II) strength/endurance (quantitative measures using accurate devices) with comparison to contralateral side or normative data base. This testing may include isometric, isokinetic, or isoinertial devices in one or more planes.

(iii) Functional abilities tests, which include the following:

(I) activities of daily living (standardized tests of generic functional tasks such as pushing, pulling, kneeling, squatting, carrying, and climbing);

(II) hand function tests which measure fine and gross motor coordination, grip strength, pinch strength, and manipulation tests using measuring devices;

(III) submaximal cardiovascular endurance tests which measure aerobic capacity using stationary bicycle or treadmill; and

(IV) static positional tolerance (observational determination of tolerance for sitting or standing).

(D) Muscle testing shall be billed using the "Physical performance test or measurement..." CPT code with modifier "-MT." Muscle testing requires a report to be submitted with the bill, identifying the service provided, results, and interpretation of the test and shall be reimbursed per body area. If two or more contiguous areas are injured and if testing requires no additional tasks, then reimbursement shall be allowed for only one body area. Muscle testing shall not be reimbursed in addition to a FCE. Muscle testing may be used to replace any six components of the functional abilities test required in a FCE and shall be reimbursed as a component of the FCE.

(i) Isometric measurements (testing for strength deficits) are reimbursed as follows:

(I) Single area: testing one injured area of the body. This includes multiple tasks and/or multiple planes.

(II) Two areas: testing two injured areas of the body. Each area requires multiple tasks and/or multiple planes. DOP is required supporting the need for testing of two areas.

(III) Multiple areas: testing more than two injured areas of the body. Each area requires multiple tasks and/or multiple planes. DOP is required supporting the need for testing of multiple body areas.

(ii) Isokinetic measurements (testing for strength deficits) are reimbursed as follows:

(I) Single area: testing one injured area of the body. This includes multiple tasks and multiple planes.

(II) Two areas: testing two injured areas of the body. Each area requires multiple tasks and multiple planes. DOP is required supporting the need for testing of two body areas.

(III) Multiple areas: testing more than two injured areas of the body. Each area requires multiple tasks and multiple planes. DOP is required supporting the need for testing of multiple body areas.

(E) When performing manual muscle testing and/or range of motion testing, reimbursement includes testing with comparison to normal side, which shall not be billed or reimbursed separately.

(3) Return To Work Rehabilitation Programs. The following shall be applied 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.

(A) Accreditation by the Commission for Accreditation of Rehabilitation Facilities (CARF) is recommended, but not required.

(i) 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% of the MAR.

(ii) 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 70% of the MAR.

(B) Work Conditioning/General Occupational Rehabilitation Programs (for TWCC purposes, CARF accredited General Occupational Rehabilitation Programs are considered Work Conditioning.)

(i) The first two hours of each session shall be billed and reimbursed as one unit, using code 97545 with "-WC" modifier. Each additional hour shall be billed as 97546 with "-WC modifier." CARF accredited Programs shall add "-CA" as a second modifier.

(ii) Reimbursement shall be $36.00 per hour. Units of less than 31 minutes shall not be billed or reimbursed.

(C) Work Hardening/Comprehensive Occupational Rehabilitation Programs (for TWCC purposes, CARF accredited Comprehensive Occupational Rehabilitation Programs are considered Work Hardening.)

(i) The first two hours of each session shall be billed and reimbursed as one unit, using code 97545 with "-WH" modifier. Each additional hour shall be billed as 97546 with "-WH" modifier. CARF accredited Programs shall add "-CA" as a second modifier.

(ii) Reimbursement shall be $64.00 per hour. Units of less than 31 minutes shall not be billed or reimbursed.

(D) Outpatient Medical Rehabilitation Programs

(i) Program shall be billed and reimbursed using 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.

(ii) Reimbursement shall be $90.00 per hour. Units of less than 31 minutes shall not be billed or reimbursed.

(E) Chronic Pain Management/Interdisciplinary Pain Rehabilitation Programs

(i) Program shall be billed and reimbursed using 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.

(ii) Reimbursement shall be $100.00 per hour. Units of less than 31 minutes shall not be billed or reimbursed.

(e) Surgery Ground Rules. HCPs billing professional medical services in the Surgery section of the AMA CPT shall utilize the following for correct coding, reporting, billing, and reimbursement of the Surgery CPT codes.

(1) Global Fee Concept. The concept of a global fee for surgical procedures is a long established concept under which a single fee (i.e., bundled service) is billed and reimbursed for services that are necessary and integral in accomplishing the surgical procedure. The surgeon normally performs these necessary services before, during, and after the surgical procedure.

(A) The global reimbursement includes the pre-operative care necessary for the specific surgical procedure, completion of hospital records, initiation of treatment, local anesthesia (including local infiltration, metacarpal/digital block, or topical anesthesia), the surgical procedure, and uncomplicated post-operative care that normally follows the specific surgical procedure. Integral parts of a surgical procedure shall not be billed with a separate charge for each service (unbundled) or reimbursed separately.

(B) If the management of a surgical procedure (pre-operative care and/or post-operative care) and the surgical procedure are performed by two or more doctors, the global fee concept shall still be applied and the appropriate CPT code shall be billed with either CPT modifier "-54," "-55," or "-56." (For additional information on these modifiers see paragraph (3) of this subsection).

(C) Included in the global period for surgery is all preoperative care, beginning with the day prior to surgery. If the HCP needs to report a preoperative visit for documentation purposes only, the HCP shall bill the appropriate CPT code with modifier "-GS."

(D) Post-operative follow-up care is included in the global period for surgery and the following shall apply.

(i) The number of consecutive post-operative follow-up days allowed is for the primary procedure.

(ii) When an additional surgical procedure is carried out within the listed period of follow-up care for a previous surgery, the follow-up periods shall continue concurrently to their normal termination.

(iii) Routine operative pain management provided by the surgeon is included in the global fee

(E) HCPs billing surgical services shall use the most current edition of the American Academy of Orthopaedic Surgeons' Complete Global Services Data for Orthopaedic Surgery in determining whether and how surgical services should be bundled.

(F) The following pre-operative services are exempt from the global fee concept and additional charges and reimbursements shall be warranted for these:

(i) Evaluation and management services unrelated to the primary procedure;

(ii) Services required to stabilize the patient for the primary procedure; and

(iii) Procedures not usually part of the basic surgical procedure (eg., bronchoscopy prior to chest surgery) provided during the immediate pre-operative period.

(G) Surgical procedures that are identified as starred procedures in the AMA CPT are not subject to the global fee concept.

(2) Multiple Procedures. Procedures performed at the same operative setting which significantly increase time and skill requirements are subject to the Multiple Procedure Rule (MPR) reimbursement and are identified by adding CPT modifier "-51" to the appropriate CPT code.

(A) The MPR reimbursement shall be as follows:

(i) 100% of the MAR for the major procedure. For MFG reimbursement purposes the major procedure is the procedure reflecting the greatest MAR value. Modifier "-51" shall not be added to the major procedure code.

(ii) 50% of the MAR for the secondary procedure. CPT modifier "-51" shall be added to the secondary procedure code.

(iii) 25% of the MAR for each subsequent procedure. CPT modifier "-51" shall be added to subsequent procedure code(s).

(B) Secondary or subsequent procedures are reimbursed when:

(i) the secondary or subsequent procedures are performed through the same incision and related to the major procedure;

(ii) the secondary or subsequent procedures are not performed through the same incision but are related to the major procedure;

(iii) the secondary or subsequent procedures are performed through the same incision and consume significant time or are due to a complication unless the additional procedure(s) is an integral part of the major procedure (in that case no additional fee shall be reimbursed); or

(iv) the secondary or subsequent procedures are performed in a remote area, but are related to the major procedure.

(C) The MPR shall not be applied to secondary or subsequent procedures performed in remote areas that are unrelated to the major procedure and require additional preparation.

(3) Surgical Modifiers. The following provisions apply to the billing and reimbursement of surgical CPT codes with the listed modifiers.

(A) Surgical Care Only, CPT modifier "-54": When one doctor performs a surgical procedure and another doctor provides preoperative and/or postoperative management, surgical services are identified by adding CPT modifier "-54" to the CPT code. Reimbursement shall reflect a reduction to allow for services provided by the other (non-operating) doctor. DOP is required.

(i) When coordinating with another doctor to provide the postoperative management, reimbursement shall be 70% of the MAR of the surgical procedure.

(ii) When coordinating with another doctor to provide the preoperative management, reimbursement shall be 90% of the MAR.

(iii) When coordinating with another doctor(s) to provide both the preoperative and postoperative management, reimbursement shall be 60% of the MAR.

(B) Postoperative Management Only, CPT modifier "-55": When one doctor performs the postoperative management and another doctor has performed the surgical procedure, the postoperative component is identified by adding CPT modifier "-55" to the CPT code. Reimbursement to the surgeon shall reflect a reduction to allow for services provided by the subsequent doctor. Reimbursement shall be 30% of the MAR of the surgical procedure. DOP is required.

(C) Preoperative Management Only, CPT modifier "-56": When one doctor performs the preoperative care and evaluation and another doctor performs the surgical procedure, the preoperative component is identified by adding CPT modifier "-56" to the CPT code. Reimbursement to the surgeon shall reflect a reduction to allow for services provided by the preceding doctor. Reimbursement shall be 10% of the MAR of the surgical procedure. DOP is required.

(D) Two Surgeons, CPT modifier "-62": When the skills of two surgeons are required in the management of a specific procedure the modifier "-62" shall be added to the CPT procedure code. Reimbursement shall be in accordance with the MPR. For an exception to this reimbursement methodology, see paragraph (5)(C) of this subsection. DOP is required.

(i) The total reimbursement for each procedure performed by the two surgeons shall not exceed 125% of the reimbursement amount for each surgical procedure.

(ii) The total reimbursement shall be apportioned according to prior agreement between both surgeons. Each surgeon shall indicate the percentage of total reimbursement agreed upon on the submitted bill.

(iii) If subsequent procedure(s) are solely performed by either surgeon during the same surgical session, these separate CPT code(s) shall be billed without the "-62" CPT modifier. Reimbursement shall be the MAR of the surgical procedure and the MPR shall be applied.

(iv) If one of the surgeons assists the other in the performance of any subsequent procedure(s) during the same surgical session, the surgeon assisting shall bill using CPT modifier "-80" for only those procedures in which the assistance rendered is medically necessary. Reimbursement shall be as specified by subparagraph (F) of this subsection. DOP is required.

(E) Surgical Team, CPT modifier "66": The total reimbursement of team doctors shall not be greater than 100% of the MAR for the surgical procedure(s). The MPR reimbursement applies. DOP is required

(F) Assistant Surgeon, CPT modifier "-80": When using this modifier, documentation shall indicate the amount of time spent by the assistant surgeon in the operative session and the need for an assistant surgeon. Documentation shall substantiate the attendance of the assistant surgeon 70% of the time during the performance of one operative session. The reimbursement shall be 25% of the MAR of the surgical procedure(s).

(G) Minimum assistant surgeon, CPT modifier "-81": When using this modifier, documentation shall indicate the amount of time spent by the assistant surgeon in the operative session and the need for an assistant surgeon. The reimbursement shall be 20% of the MAR of the surgical procedure(s).

(H) Assistant Surgeon (when qualified resident surgeon not available), CPT modifier "-82": When using this modifier, documentation shall indicate the amount of time spent by the assistant surgeon in the operative session and the need for an assistant surgeon. The reimbursement shall be 20% of the MAR of the surgical procedure(s).

(I) Surgical Assistant, modifier "-SA": For services provided by a Certified Physician Assistant (PA) or a Certified Surgical Technologist/Certified First Assistant (CST/CFA) in lieu of an Assistant Surgeon, the Certified PA and the CST/CFA shall bill using the appropriate CPT code with modifier "-SA." The following shall apply to Certified PAs and CST/CFAs:

(i) Only individuals who satisfy the certification requirements for Certified PA or CST/CFA are eligible for reimbursement.

(I) A PA is defined as a graduate of a physician assistant or surgeon assistant training program accredited by the American Medical Association's Committee on Allied Health, Education, and Accreditation; or, a person who has passed the certifying examination administered by the National Commission on the Certification of Physician Assistants, and who is licensed as a physician assistant by the Physician Assistant Advisory Council.

(II) A CST/CFA is defined as a graduate from a surgical technology program accredited by the Committee on Allied Health Education and Accreditation or from a program acceptable to the Liaison Council on Certification for the Surgical Technologist. A CST/CFA is certified as a Certified Surgical Technologist and as a Certified First Assistant.

(ii) The services of a Certified PA or CST/CFA (in lieu of an Assistant Surgeon) requires documentation that supports the specific need for a surgical assistant. The documentation shall identify the appropriateness of the services of the Certified PA or CST/CFA in lieu of the services of an Assistant Surgeon.

(iii) The Certified PA or CST/CFA, when acting as an assistant to the surgeon during the operation does so under the direction and supervision of that surgeon and in accordance with hospital policy and appropriate laws and regulations.

(iv) An Assistant Surgeon and a Certified PA or CST/CFA cannot both bill or be reimbursed for the same surgical case.

(v) Total reimbursement shall be 10% of the listed MAR of the surgical procedure.

(4) Spinal Instrumentation/Prosthetics. The following provisions apply to the billing and reimbursement of spinal instrumentation/prosthetics.

(A) Reimbursement shall be allowed posteriorly and/or anteriorly for the placement of the fixation devices.

(B) When billing and reimbursing the "Application of intervertebral biomechanical device(s) ...to vertebral defect or interspace" CPT code, the following shall apply:

(i) The "Application of intervertebral biomechanical device(s) ...to vertebral defect or interspace" CPT code shall only be billed and reimbursed one time if one or more synthetic cages are placed in the intervertebral space at the same level.

(ii) If synthetic cages are placed at two or more different levels (e.g., synthetic cage placed at L3-4 interspace and L5-S1 interspace), then the "Application of intervertebral biomechanical device(s) ...to vertebral defect or interspace" CPT code shall be billed and reimbursed per level.

(iii) If a single synthetic cage can cover a defect of several vertebral levels (e.g., a single synthetic cage may replace three entire vertebrae), then the "Application of intervertebral biomechanical device(s) ...to vertebral defect or interspace" CPT code shall only be billed and reimbursed one time.

(5) Arthrodesis. The following provisions apply to the billing and reimbursement of arthrodesis services.

(A) All vertebral arthrodesis procedures include vertebral graft preparations, such as:

(i) minimal diskectomy, other than for decompression, necessary to accomplish the arthrodesis;

(ii) perforation or resection of vertebral end plates;

(iii) graft preparation with autologus blood components and bone marrow products; and

(iv) preparation and insertion of synthetic bone substitutes (e.g., hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix, gels and putty).

(B) Combination anterior/posterior spinal procedures shall be billed using the CPT codes for both anterior and posterior arthrodesis with modifier "-AP" added to both CPT codes. If no other vertebral procedure, other than the arthrodesis, is performed the MPR does not apply.

(C) When the approach for arthrodesis of the anterior spine is performed by a different surgeon, both surgeons shall bill using the CPT code for the anterior arthrodesis performed, with CPT modifier "-62."

(i) Reimbursement, in this case, for each surgeon shall be 75% of the anterior arthrodesis CPT code MAR.

(ii) When two surgeons bill for an anterior arthrodesis procedure, then an Assistant Surgeon and/or a Surgical Assistant shall not bill or be reimbursed for the anterior arthrodesis procedure.

(6) Bilateral Procedures. Certain CPT codes for bilateral procedures identify both sides of the procedure, whereas other CPT codes identify only half of the bilateral procedure. Bilateral procedures are reimbursed according to the MPR.

(A) When a CPT code identifies half of a bilateral procedure, the second half of the bilateral procedure shall be billed using the appropriate CPT code with CPT modifier "-50." The MPR shall apply.

(B) A CPT code which identifies both portions of a bilateral procedure (e.g., spinal procedures: fusions, instrumentations, and/or nerve decompression procedures) shall only be billed and reimbursed once

(7) Surgical Injections. The following provisions apply to the billing and reimbursement of surgical injection services.

(A) Surgical injections delineated as "per injection" by CPT descriptor and nomenclature warrant additional reimbursement per injection subject to the MPR within the same body area.

(B) Injections delineated as "per level" by CPT descriptor and nomenclature are considered bilateral.

(C) When introducing additional materials through the same puncture site, reimbursement shall be allowed for the materials only. Materials shall be billed using the appropriate HCPCS code, when possible, or the "Supplies and materials..." CPT code. DOP is required. The surgical procedure code shall be billed and reimbursed only once.

(D) When therapeutic injection procedures are performed at an established patient office visit, an office visit charge is indicated only if a significant re-evaluation was necessary. The HCP shall bill and be reimbursed a "minimal" office visit E/M CPT code. DOP is required.

(E) Botulinum toxin (BOTOX) injections shall be billed and reimbursed using the "Unlisted procedure, nervous system" CPT code with modifier "-BX."

(8) Replantation CPT codes shall be reimbursed 100% of the MAR for each replantation procedure. Each digit is considered one replantation procedure. When extensive complications necessitate additional procedures, the MPR shall apply and DOP is required.

(9) Manipulation Under Anesthesia. The following provisions apply to the billing and reimbursement of Manipulation Under Anesthesia (MUA)

(A) MUAs shall be reimbursed only once per body region per session. Appropriate body regions are listed in AMA CPT.

(B) Manipulation of a joint under anesthesia preceded or followed by a surgical procedure on the same joint on the same day shall not be billed or reimbursed separately from the surgical procedure

(10) Neurostimulators (Spinal). Placement of any additional electrode catheter(s)/array(s) or plate(s)/paddle(s) shall be billed and reimbursed separately by adding CPT modifier "-51" to the appropriate CPT code.

(11) Incidental Procedure. An incidental procedure is defined as a surgery performed through the same incision at the same operative session by the same doctor and which is not related to the diagnosis or disorder the operative session was intended for. An incidental procedure (e.g., an appendectomy during a cholecystectomy) shall not be billed or reimbursed separately.

(12) Services Necessary to Stabilize Patient. If an injured employee has a medical condition (e.g., diabetes), then all services necessary to stabilize the injured employee so that surgery or other treatment may be performed safely and/or effectively shall be billed and reimbursed separately. DOP is required.

(13) Surgical Procedures Performed in a Doctor's Office. The following provisions apply to the billing and reimbursement of surgical procedures performed in a doctor's office.

(A) In order for the doctor's office to qualify for facility reimbursement for surgical procedures performed in a doctor's office, the office shall meet all of the following requirements:

(i) a complete and routinely checked crash cart; either a registered nurse, CRNA, or a doctor dedicated to the "facility" room;

(ii) a separate observation or recovery room;

(iii) patient monitoring equipment, including EKG and pulse oximetry equipment; and

(iv) support staff and equipment to ensure that the care received by the patient is the same as that, which would have been in an ambulatory surgical center or in the outpatient surgical ward of a hospital.

(B) If the above listed requirements are met, the only billing and reimbursements allowed for facility charges shall be the following:

(i) Sterile trays (which include all supplies, gloves, utensils, needles, suture material, etc., needed to perform the procedure). These shall be billed using the "Supplies and materials..." CPT code with modifier "-ST". DOP is required if charges billed are $50.00 or greater.

(ii) Anesthesia supplies (which include the administration of the sedative, the IV solution, the catheter/tubing, and drugs.): No additional billing or reimbursement shall be allowed for equipment or staffing. (If the services require the use of complex or prolonged anesthesia or the need for an anesthesiologist or CRNA, the service shall be performed in a hospital or ambulatory surgical center.) This service shall be billed using the "Supplies and materials..." CPT code with modifier "-AS". DOP is required if charges billed are $50.00 or greater.

(iii) Postoperative monitoring (includes the facility, staffing and monitoring equipment): This service shall be billed using the "Unlisted evaluation and management service" code with modifier "-RO". No separate billing or reimbursement shall be allowed for HCP stand-by. Reimbursement shall be per hour and the maximum amount of time allowed shall be four hours. DOP is required.

(14) Operating Microscope. The "Operating Microscope" CPT code shall not be billed or reimbursed in addition to CPT codes that state use of the operating microscope is an inclusive component of the procedure (i.e., the procedure description specifies microsurgical techniques are used), or if another CPT code describes the same procedure being done with an operating microscope. DOP is required.

(15) Intra Discal Electro Thermal (IDET). IDET shall be billed and reimbursed using the "Unlisted procedure, nervous system" CPT code with modifier "-ID."

(f) Anesthesia Ground Rules. HCPs billing Anesthesia professional medical services in the Anesthesia section of the AMA CPT shall utilize the following for correct coding, reporting, billing, and reimbursement of the Anesthesia CPT codes.

(1) General Information and Instructions. The following general provisions apply.

(A) The anesthesiologist providing the medical direction shall remain on-site in the operating suite, and shall extend medical direction to no more than four concurrent anesthetic procedures.

(B) Medical direction excludes simultaneous administration of anesthesia and performance of surgical services by the directing anesthesiologist.

(C) Only the anesthesiologist providing concurrent supervision shall bill and be reimbursed the Total Anesthesia Reimbursement (TAR) of the procedure.

(D) Independent Certified Registered Nurse Anesthetists (CRNAs) may bill and shall be reimbursed when providing anesthesia care within the CRNA scope of practice as defined by state law.

(E) Local infiltration, metacarpal/digital block, or topical anesthesia administered by the surgeon is included in the MAR for the surgical procedure, and shall not be billed or reimbursed separately.

(F) Major regional anesthesia, such as spinal epidural and major peripheral nerve blocks, administered by the surgeon shall be reimbursed according to the basic anesthesia value. Time shall not be billed or reimbursed separately. The appropriate surgical CPT code shall be billed with CPT modifier "-47."

(G) If the major regional anesthesia is provided by the anesthesiologist or CRNA, then reimbursement shall be the basic value, plus any modifying factors, plus time units.

(H) Regional anesthesia excludes the administration of sedatives, tranquilizers, analgesics and other hypnotics, and the oral administration of these shall not be billed or reimbursed separately.

(I) Only the surgeon, anesthesiologist, or CRNA administering diagnostic or therapeutic nerve block(s) shall bill and be reimbursed for the surgical procedure(s). Anesthesia time units shall not be billed or reimbursed in addition to the surgical procedure.

(J) When an anesthesiologist or CRNA bills for a procedure found in another section, then the ground rules of that section shall apply to the CPT code (e.g., injections).

(K) Provisions regarding Conscious Sedation CPT codes are contained in subsection (c) of this section.

(2) Separate or Multiple Procedures. No additional basic value shall be reimbursed for anesthesia provided during additional surgical procedures (other than the major procedure) performed on the same day during the same operative setting. Anesthesia reimbursement for multiple procedures is based on the procedure with the highest basic value, plus modifying factors, plus total time units for all combined surgical procedures.

(3) Billing. The following provisions apply to the billing of Anesthesia services.

(A) Total units shall appear in the units column of the bill (base value + time + modifying units).

(B) Total anesthesia time (in minutes) shall be listed on the bill.

(C) When billing for daily hospital management of intravenous patient-controlled analgesia by an anesthesiologist, the "Unlisted anesthesia procedure(s)" CPT code shall be billed and reimbursed. The TAR shall be calculated using a basic value of 2 units, and neither time units nor modifying factors shall be billed or reimbursed additionally. DOP is required.

(D) Anesthesia for Manipulation Under Anesthesia (MUA), shall be billed and reimbursed using the "Unlisted anesthesia procedure(s)" CPT code. The TAR shall be calculated by using a basic value of 5 units, and neither time units nor modifying factors shall be billed or reimbursed additionally.

(E) Anesthesia services that necessitate the skills and time of the anesthesiologist or CRNA beyond what is usually required (e.g., unusual forms of monitoring, severe multiple injuries, or other factors requiring extended pre- and/or post-operative care), shall be billed using the appropriate anesthesia CPT code with CPT modifier "-22." DOP is required.

(F) Any procedure around the head, neck or shoulder girdle that requires field avoidance; or any procedure compromising the anesthesia administration (e.g., requiring a position other than supine or lithotomy) shall have a minimum basic value of 5.0 units regardless of any lesser basic value assigned to such procedure. The appropriate anesthesia CPT code shall be billed with CPT modifier "-22." DOP is required.

(g) Radiology Ground Rules. HCPs billing professional medical services in the Radiology section of the AMA CPT shall utilize the following for correct coding, reporting, billing, and reimbursement of the Radiology CPT codes.

(1) Imaging centers and radiologic centers (not covered by a hospital's license) shall bill on the HCFA-1500 form.

(2) A complete radiological examination includes all of the necessary views for optimal examination of the body part. Single views comprising a complete examination shall not be billed or reimbursed separately. If the reimbursement of multiple single view CPT codes exceeds the reimbursement of a complete examination CPT code, reimbursement shall be the complete examination CPT code MAR.

(3) When procedures found in another section are performed, then the Ground Rules of that section shall apply to the CPT code (e.g., injections).

(4) The following provisions apply to the billing and reimbursement of the components of radiological services.

(A) To identify a charge for only the professional component of a radiological service, the appropriate CPT code shall be billed with CPT modifier "-26." A written report, signed by the interpreting doctor, shall be considered an integral part of a radiologic procedure or interpretation and shall not be billed or reimbursed separately. The professional component MAR represents the total reimbursement for the professional radiological services of the doctor. The professional component includes:

(i) examination of the patient, when indicated;

(ii) performance and/or supervision of the procedure;

(iii) interpretation, and written report of the examination; and,

(iv) consultation with the referring doctor.

(B) To identify a charge for only the technical component of a radiological service, the appropriate CPT code shall be billed with modifier "-TC." The technical component MAR represents the total reimbursement for the technical services associated with the radiological procedure (with the exception of the cost of radioisotopes, which are reimbursed separately). The technical component includes:

(i) personnel services;

(ii) materials (including ionic contrast media and drugs);

(iii) film or xerograph;

(iv) office space;

(v) equipment; and,

(vi) other facility resources.

(C) To identify a charge for the whole procedure, the appropriate CPT code shall be billed with modifier "-WP." The whole procedure MAR represents the total reimbursement for the professional component and the technical component of the radiological service. Whole procedure MARs are applicable in any situation in which a single charge is made to include both professional services and the technical cost of providing radiological services.

(5) The MARs for injection procedures performed in conjunction with radiological procedures include:

(A) all usual pre-injection and post-injection care specifically related to the injection procedure;

(B) necessary local anesthesia;

(C) placement of needle or catheter; and,

(D) injection of contrast material (with or without auto power injection).

(6) The following provisions apply to the billing and reimbursement of fluoroscopic assistance.

(A) If fluoroscopic assistance (fluoroscopy) is medically necessary when performing an injection, and it is not included in the injection procedure, the HCP shall bill the appropriate injection CPT code and the appropriate fluoroscopy CPT code. DOP is required.

(B) If a videotape of the fluoroscopic assistance (videofluoroscopy) is medically necessary when performing an injection, the HCP shall bill the appropriate injection CPT code and the appropriate fluoroscopy CPT code with modifier "-VT" (for the videotape). DOP is required.

(C) Fluoroscopic assistance is considered part of a myelogram or discogram and shall not be billed or reimbursed separately for those procedures.

(7) The following provisions apply to the billing and reimbursement of contrast materials.

(A) Ionic contrast material for radiological procedure(s) is considered part of the procedure and shall not be billed or reimbursed separately.

(B) Non-ionic contrast material for radiological procedure(s) (excluding material for MRIs) shall be billed and reimbursed using the "Supply of low osmolar contrast material" HCPCS codes.

(C) Contrast material for MRI procedures shall be billed using the "Supply of paramagnetic contrast material" HCPCS code when use of contrast material is medically necessary.

(h) Pathology Ground Rules. HCPs billing professional medical services in the Pathology section of the AMA CPT shall utilize the following for correct coding, reporting, billing, and reimbursement of the Pathology CPT codes.

(1) The MARs for Pathology CPT codes include recording the specimen, performance of the test, and reporting the result. The Pathology MARs do not include specimen collection/transfer or individual patient administrative services.

(2) The following provisions apply to the billing and reimbursement of the components of pathology services.

(A) To identify a charge for the professional component only, the appropriate CPT code shall be billed with CPT modifier "-26." The professional component MAR represents the total reimbursement for the professional pathology services of the doctor. The professional component includes:

(i) examination of the patient, when indicated;

(ii) performance and/or supervision of the procedure, or lab test;

(iii) interpretation and/or written report of the examination, or lab test; and,

(iv) consultation with the referring doctor.

(B) To identify a charge for the technical component only, the appropriate CPT code shall be billed with modifier "TC." The technical component MAR represents the total reimbursement for the technical services associated with the pathology procedure. The technical component includes:

(i) personnel services;

(ii) materials;

(iii) office space;

(iv) equipment; and,

(v) other facility resources normally included in providing the service.

(C) To identify a charge for the whole procedure, the appropriate CPT code shall be billed with modifier "-WP." The whole procedure MAR represents the total reimbursement for the professional component and the technical component of the pathology service. Whole procedure MARs are applicable in any situation in which a single charge is made to include both professional services and the technical cost of providing such services.

(3) Billing for pathology services may be done by the office that collected the specimen or by the laboratory that performed the testing on the specimen.

(A) If the billing for the laboratory testing is done by the office collecting the specimen (e.g., the doctor's office), then the appropriate CPT code with CPT modifier "-90" shall be billed. Billing for those CPT codes shall only be what is charged to the collecting office by the reference laboratory (i.e., the laboratory performing the tests). In addition, the collecting office shall bill for a "handling" charge using CPT codes from the Medicine section.

(B) If the billing for the laboratory testing is done by the reference laboratory, not the collecting office, then the appropriate CPT code shall be billed and CPT modifier "-90" shall not be added. The collecting office (e.g., the doctor's office) shall only bill for a "handling" charge using CPT codes from the Medicine section.

(4) When billing for panel tests, the CPT code corresponding to the appropriate panel test shall be billed and reimbursed. Tests comprising the panel shall not be billed or reimbursed separately. Tests performed in addition to a particular panel or a second panel of tests shall be billed and reimbursed separately.

(i) TWCC Specific Services. HCPs billing TWCC Specific Services shall utilize the following for correct coding, reporting, billing, and reimbursement of these services.

(1) Spinal Surgery Second Opinions pursuant to §133.206 of this title (relating to Spinal Surgery Second Opinion Process) shall be billed and reimbursed as follows.

(A) The following codes shall be billed for spinal surgery second opinion services:

(i) WC001--for spinal surgery second opinion examinations;

(ii) WC002--if the injured employee fails to show up for a scheduled spinal surgery second opinion examination or if a spinal surgery second opinion examination is canceled by the injured employee with less than twenty four hours notice; and,

(iii) WC003--for reconsideration of an earlier decision, which will include a review of an injured employee's case regardless of whether a change of condition exists.

(B) The MARs for Spinal Surgery Second Opinions are:

(i) WC001--$350.00

(ii) WC002--$100.00

(iii) WC003--$150.00

(2) Maximum Medical Improvement and/or Impairment Rating (MMI/IR) shall be billed and reimbursed as follows.

(A) The total MAR for an MMI/IR examination shall be equal to the MMI examination reimbursement plus the reimbursement for the body area(s) rated for the assignment of an IR. The total MAR for determination of MMI/IR shall include:

(i) the examination;

(ii) consultation with the injured employee;

(iii) review of the records and films;

(iv) the preparation and submission of reports (including TWCC required forms, narrative report, and responding to the need for further clarification, explanation, or reconsideration), calculation tables, figures, and worksheets;

(v) range of motion, strength and sensory testing, and measurements; and,

(vi) other tests used to validate the IR.

(B) For IR testing, the HCP shall indicate the number of body areas rated in the units column of the billing form. Body areas shall be billed and reimbursed as follows:

(i) The examining doctor may bill for a maximum of three musculoskeletal body areas.

(I) Musculoskeletal body areas are defined as follows:

(-a-) spine and pelvis;

(-b-) upper extremities and hands; and,

(-c-) lower extremities (including feet).

(II) The MAR for musculoskeletal body areas shall be:

(-a-) one musculoskeletal body area: $300.00; and,

(-b-) each additional musculoskeletal body area: $150.00.

(III) When the examining doctor conducts the MMI examination and the IR testing, the examining doctor shall bill using the appropriate MMI/IR code with modifier "-WP." Reimbursement shall be 100% of the total MAR.

(IV) If the examining doctor conducts the MMI examination and determines the assignment of IR, excluding the testing, then the examining doctor shall bill using the appropriate MMI/IR code with CPT modifier "-26." Reimbursement shall be 80% of the total MAR.

(V) If testing is performed by a HCP other than the examining doctor, then the HCP shall bill using the appropriate MMI/IR code with modifier "-TC." Reimbursement shall be 20% of the total MAR.

(ii) Other body areas shall be billed and reimbursed using the appropriate CPT code(s) for the tests required for the assignment of IR.

(I) Other body areas are follows:

(-a-) body systems;

(-b-) body structures (including skin); and,

(-c-) mental and behavioral disorders.

(II) For a complete list of these body areas refer to the AMA Guides to the Evaluation of Permanent Impairment, as stated in the commission Act and Rules Chapter 130 relating to Impairment and Supplemental Income Benefits.

(C) When testing is required for the assignment of IR and the examining doctor refers the testing to a specialist, then the following shall apply:

(i) The examining doctor (e.g., the referring doctor) shall bill specialist referred testing as one unit on the billing form using the appropriate MMI/IR code. Reimbursement shall be $50.00 for incorporating one or more specialists' report information into the final IR. This reimbursement shall be allowed only once per examination.

(ii) The referral specialist shall bill and be reimbursed for the appropriate CPT code(s) for the tests required for the assignment of IR. DOP is required.

(D) The treating doctor shall bill for an MMI/IR examination using the "Work related or medical disability examination by the treating physician..." CPT code with the appropriate modifier.

(i) Reimbursement for the determination of MMI shall be the applicable established patient office visit level associated with the examination. Modifiers "-T1", "-T2", "-T3", "-T4", or "-T5" shall be added to the "Work related or medical disability examination by the treating physician..." CPT code to correspond with the last digit of the applicable office visit.

(ii) Reimbursement for the determination of an IR shall be according to the areas rated.

(iii) If the treating doctor refers the injured employee to another doctor for the certification of MMI and assignment of IR and the referral doctor has:

(I) not previously treated the injured employee, then the referral doctor shall bill using the "Unlisted evaluation and management service" CPT code and the reimbursement shall be as outlined for Required Medical Examinations (RME); or,

(II) previously been treating the injured employee, then the billing and reimbursement shall be as outlined for the treating doctor.

(iv) The treating doctor is required to review the certification of MMI and assignment of IR performed by another doctor (other than the designated doctor) as required by Chapter 130 of this title. The treating doctor shall bill using the "Work related or medical disability examination by the treating physician..." CPT code with modifier "-RP" to indicate a review of the report only, and shall be reimbursed $50.00.

(E) A designated doctor shall bill for an MMI/IR examination using the "Work related or medical disability examination by other than the treating physician..." CPT code with the appropriate modifier.

(i) Reimbursement for the determination of MMI shall be based on the amount of time that has elapsed since the date of injury (DOI). One of the following modifiers shall be added to the "Work related or medical disability examination by other than the treating physician..." CPT code:

(I) D1 (less than one year since the DOI)--$200.00

(II) D2 (greater than or equal to one year and less than two years since the DOI)--$300.00

(III) D3 (greater than or equal to two years since the DOI)--$400.00

(ii) Reimbursement for the determination of an IR shall be according to the areas rated. If the testing is performed by a HCP other than the designated doctor, then to qualify for reimbursement, the testing HCP shall:

(I) not have previously examined or treated the injured employee within the past 12 months, or with regard to the medical condition being evaluated by the designated doctor; and,

(II) must have successfully completed commission-approved training in the proper use of the AMA Guides.

(iii) When the result of the evaluation is that MMI has not been reached, the total reimbursement shall be $350.00. This reimbursement shall include all services required for an MMI/IR examination excluding those services unique to assigning an IR. The designated doctor shall bill using the "Work related or medical disability examination by other than the treating physician..." CPT code with modifier "-NM."

(iv) Appointments canceled or not attended by the injured employee, with less than 24 hours notice to the designated doctor, shall be billed using the "Work related or medical disability examination by other than the treating physician..." CPT code with modifier "-BA" and the reimbursement shall be $100.00.

(F) A doctor performing a Required Medical Examination (RME) for the purpose of certifying MMI and assigning an IR shall bill using the "Unlisted evaluation and management service" CPT code with the appropriate modifier.

(i) Reimbursement for the determination of MMI shall be based on the amount of time that has elapsed since the date of injury (DOI). One of the following modifiers shall be added to the "Unlisted evaluation and management service" CPT code:

(I) R1 (first RME if less than one year from DOI or any subsequent RMEs)--$100.00

(II) R2 (first RME if greater than or equal to one year and less than two years since the DOI)--$200.00

(III) R3 (first RME if greater than or equal to two years since the DOI)--$300.00

(ii) Reimbursement for the determination of an IR shall be according to the areas rated.

(iii) When the result of the evaluation is that MMI has not been reached, the total reimbursement shall be $350.00. This reimbursement shall include all services required for an MMI/IR excluding those services unique to assigning an IR. The RME doctor shall bill using the "Unlisted evaluation and management service" CPT code with modifier "-NM."

(iv) Appointments scheduled by the commission or the insurance carrier and canceled or not attended by the injured employee, with less than 24 hours notice to the doctor, shall be billed using the "Unlisted evaluation and management service" CPT code with modifier "-BA" and the reimbursement shall be $100.00.

(v) An injured employee's treating doctor attending an RME shall bill using the "Unlisted evaluation and management service" CPT code with modifier "-AR." Reimbursement shall be $25.00 per 15-minute increment (any amount over ten minutes shall be considered an additional 15 minute increment). A maximum of four hours shall be allowed, unless the insurance carrier previously approved extended time.

(vi) When conducting a commission or insurance carrier requested RME that is not for the purpose of certifying MMI/IR (e.g. evaluation of medical care), the RME doctor shall bill using the appropriate consultation CPT code with modifier "-RM." Appointments canceled or not attended by the injured employee with less than 24 hours notice to the HCP shall be billed using the "Unlisted evaluation and management service" CPT code with modifier "-BA," and reimbursement shall be $50.00.

(3) When a designated doctor is appointed by the commission to perform an examination to resolve a return to work dispute, the designated doctor shall bill using the "Unlisted evaluation and management service" CPT code with modifier "-RW." The reimbursement shall be $500.00 and shall include commission-required reports. Appointments scheduled by the commission and canceled or not attended by the injured employee, with less than 24 hours notice to the designated doctor, shall be billed using the "Unlisted evaluation and management service" CPT code with modifier "-BA" and the reimbursement shall be $100.00

(4) When billing for a Work Status Report refer to the commission Act and Rules Chapter 129 relating to Income Benefits--Temporary Income Benefits.

(j) HCPCS Level II. HCPs billing HCPCS Level II codes shall utilize the following for correct coding, reporting, billing, and reimbursement of HCPCS codes A, E, J, K, L and modifiers.

(1) Orthotics/Prosthetics. Orthotics/Prosthetics services shall be billed using the appropriate HCPCS code (K and/or L codes). CPT codes shall only be used when the service rendered does not fit the descriptions/codes provided in the HCPCS system.

(2) Durable Medical Equipment (DME). DME refers to those items that can withstand repeated use, are primarily used to serve a medical purpose, are generally not useful to a person in the absence of illness, injury, or disease; and, are appropriate for use in the injured employee's home.

(A) The insurance carrier and/or HCP may recommend DME providers, but the injured employee shall have the right to choose the DME provider.

(B) Reimbursement shall be based upon the presumption that the injured employee is being provided high quality equipment/supplies for the treatment of the compensable work-related injury/illness.

(i) A written order/prescription shall accompany initial bills submitted to the insurance carrier for the rental or purchase of DME. Any verbal order given by the doctor to the DME provider shall be followed by a written order/prescription prior to billing for the DME equipment/supplies. DOP is required (including prognosis and the expected duration the equipment or supplies will be required).

(ii) The purchase and/or rental of DME shall be billed using the appropriate HCPCS code with a modifier.

(iii) When no HCPCS code is available for the DME and/or supplies provided to the injured employee, the DME provider shall bill using the "Durable medical equipment, miscellaneous" HCPCS code. DOP is required.

(iv) Storage, shipping, handling, taxes, etc. are included in the DME provider's usual and customary charge and shall not be billed or reimbursed separately.

(C) Supplies shall be provided on a monthly basis and only at the request of, or on behalf of, the injured employee. Documentation for distribution of supplies shall be provided when requested by the commission.

(D) Rental charges shall be based on a monthly rate unless otherwise specified.

(i) Rental charges are applicable for short-term utilization up to 60 days, unless the treating/referral doctor provides medical justification for an extension beyond the initial 60 days.

(ii) The rental payment(s) shall apply toward the purchase of the rental item.

(iii) When cumulative rental totals per item exceeds $500 (e.g. $100/month for 6 months) continued rental of the item shall be subject to the commission preauthorization rules.

(iv) The return of rented equipment is the dual responsibility of the injured employee and the DME HCP. The insurance carrier shall not be responsible for the return of rented equipment and shall not reimburse for additional rental periods solely because of a delay in equipment return.

(E) The cost of repair or maintenance of DME shall be:

(i) the responsibility of the DME provider at no additional charge, if the DME is rented; or,

(ii) the responsibility of the insurance carrier, subject to warranty provisions, if the DME is purchased from the DME provider.

(F) The DME provider shall provide a warranty agreement for those items purchased or reimbursed by the insurance carrier. The starting date of the warranty is deemed to be the date of purchase.

(i) For the purchase of a new DME item, the DME provider shall inform the injured employee and the insurance carrier of any warranty provided by the DME manufacturer.

(ii) For the purchase of a used DME item the DME provider shall provide a 90-day warranty agreement to the injured employee and the insurance carrier.

(G) Transcutaneous Electrical Nerve Stimulator (TENS) and/or Neuromuscular Electrical Nerve Stimulators (NENS) units shall meet the standards established by the American National Standard Association for the Advancement of Medical Instrumentation.

(i) The purchase price shall include:

(I) unit lead wires for a channel unit;

(II) instruction booklet;

(III) warranty information;

(IV) two (2) batteries (either replaceable or rechargeable); and,

(V) a battery charger (for rechargeable batteries).

(ii) All TENS supplies shall be itemized and billed using the "Durable medical equipment, miscellaneous" code. Reimbursement shall not exceed $85.00 per month except in those unusual cases where additional supplies are medically necessary (DOP is required). No additional supply codes shall be billed or reimbursed in addition to the "Durable medical equipment, miscellaneous" code.

(H) Continuous Passive Motion (CPM) Equipment is rented on a daily basis and shall be billed using the "Passive motion exercise device" HCPCS code. Only one set of soft goods shall be reimbursed per injured employee.

(k) Dental Services. HCPs billing dental services shall utilize the following for the correct coding, reporting, billing, and reimbursement of services.

(1) Dental services provided under the Texas Workers' Compensation Act shall include the repair or replacement of those teeth and oral structures related to the compensable injury. Examples of services that are not covered by workers' compensation insurance include:

(A) all preventative services;

(B) multiple units of fixed prosthetics exceeding the number of teeth involved in the original injury, except necessary abutments and/or implants;

(C) hair and tissue analysis;

(D) treatments based on mercury toxicity;

(E) silent period durations;

(F) jaw tracking not induced by trauma; and,

(G) mandibular kinesiography not induced by trauma.

(2) Reimbursement is allowed only when a licensed dentist is performing services within the dentist's scope of practice or when a nonlicensed individual is providing care under the direct supervision of a licensed dentist.

(3) Prefix "DS" shall be listed before each Current Dental Terminology (CDT) code.

(4) Reimbursement for laboratory procedures performed in dental laboratories are included in the reimbursement for the CDT code(s).

(5) For reimbursement of multiple procedures, the Multiple Procedure Rule in subsection (d) of this section shall be applied.

(l) TWCC Modifiers. HCPs billing professional medical services shall utilize the following modifiers, in addition to the modifiers in the documents adopted by reference in §134.203 of this title (relating to Professional Services Codes), for correct coding, reporting, billing, and reimbursement of the procedure codes.

(1) -73, Work Status Report--This modifier shall be used by doctors billing for Work Status Reports. For additional billing information refer to Chapter 129 of this title (relating to Income Benefits--Temporary Income Benefits).

(2) -AC, Anesthesia by Certified Registered Nurse Anesthetist (CRNA)--This modifier shall be added to the anesthesia CPT code(s) when the CRNA works independently of the anesthesiologist's supervision to provide the total anesthesia care.

(3) -AP, Combination Anterior/Posterior Spinal Procedures--This modifier shall be added to all surgical CPT codes performed to complete the combination anterior/posterior surgical procedure.

(4) -AR, Treating Doctor Attendance at RME--This modifier shall be added to the "Unlisted evaluation and management service" CPT code to indicate an injured employee's treating doctor attended an RME.

(5) -AS, Anesthesia Supplies--This modifier shall be added to the "Supplies and materials..." CPT code for anesthesia supplies when surgical procedures requiring anesthesia are performed in a doctor's office.

(6) -AT, Autotraction--This modifier shall be used with the "Unlisted therapeutic procedure" CPT code when autotraction is used for treatment.

(7) -A1, Supervision of a CRNA by an Anesthesiologist--This modifier shall be added to the anesthesia CPT code(s) when the Anesthesiologist is directing one anesthetic procedure. The anesthesiologist shall be reimbursed 100% of the total anesthesia reimbursement (TAR).

(8) -A2, Concurrent Supervision of Two CRNAs by an Anesthesiologist--This modifier shall be added to the anesthesia CPT code(s) when the Anesthesiologist is directing two concurrent anesthetic procedures. The reimbursement shall be at 90% of the TAR.

(9) -A3, Concurrent Supervision of Three CRNAs by an Anesthesiologist--This modifier shall be added to the anesthesia CPT code(s) when the Anesthesiologist is directing three concurrent anesthetic procedures. The reimbursement shall be at 80% of the TAR.

(10) -A4, Concurrent Supervision of Four CRNAs by an Anesthesiologist--This modifier shall be added to the anesthesia CPT code(s) when the Anesthesiologist is directing four concurrent anesthetic procedures. The reimbursement shall be at 70% of the TAR.

(11) -BA, Broken Appointment--Appointments scheduled by the commission or the insurance carrier and canceled or not attended by the injured employee, with less than 24 hours notice to the HCP, shall be billed adding modifier "-BA" to the appropriate CPT code.

(12) -BX, Botulinum toxin (BOTOX)--This modifier shall be used with the "Unlisted procedure, nervous system" CPT code when BOTOX treatment is performed.

(13) -CA, Commission of Accreditation of Rehabilitation Facilities (CARF) Accredited programs--This modifier shall be used when an HCP bills for a Return To Work Rehabilitation Program that is CARF accredited.

(14) -CM, Continuous Passive Motion--This modifier shall be used with the "Unlisted modality" CPT code when a continuous passive motion device is used for treatment.

(15) -CP, Chronic Pain Management--This modifier shall be used with the "Unlisted physical medicine/rehabilitation service or procedure" CPT code for chronic pain management.

(16) -DC, Dressing Changes--This modifier shall be used with the "Unlisted therapeutic procedure" CPT code for dressing changes.

(17) -D1, Time of MMI/IR for Designated Doctor--This modifier shall be added to the "Work related or medical disability examination by other than the treating physician..." CPT code when the amount of time that has elapsed since the date of injury is less than one year.

(18) -D2, Time of MMI/IR for Designated Doctor--This modifier shall be added to the "Work related or medical disability examination by other than the treating physician..." CPT code when the amount of time that has elapsed since the date of injury is greater than or equal to one year and less than two years.

(19) -D3, Time of MMI/IR for Designated Doctor--This modifier shall be added to the "Work related or medical disability examination by other than the treating physician..." CPT code when the amount of time that has elapsed since the date of injury is greater than or equal to two years.

(20) -EC, Taping to Stabilize or Align--This modifier shall be used with the "Unlisted therapeutic procedure" CPT code when taping is used to stabilize or align the joint.

(21) -EM, Surface EMG--This modifier shall be used with the "Unlisted physical medicine/rehabilitation service or procedure" CPT code when a surface EMG is performed.

(22) -EU, Simultaneous Electrical Stimulation/Ultrasound--This modifier shall be used with the "Unlisted therapeutic procedure" CPT code when simultaneous electrical stimulation/ultrasound is performed.

(23) -FC, Functional Capacity--This modifier shall be used with the "Physical performance test or measurement..." CPT code when a functional capacity evaluation is performed.

(24) -FT, Fluidotherapy--This modifier shall be used with the "Unlisted modality" CPT code when fluidotherapy is performed.

(25) -GS, Global Service--This modifier shall be used to denote a service that is included in a surgical procedure and is not reimbursed separately but is being documented separately.

(26) -H1, Home Health Agency Services--This modifier shall be used to indicate home health services rendered by a Registered Nurse.

(27) -H2, Home Health Agency Services--This modifier shall be used to indicate home health services rendered by a Licensed Vocational Nurse.

(28) -H3, Home Health Agency Services--This modifier shall be used to indicate home health services rendered by a Certified Nurse Assistant.

(29) -H4, Home Health Agency Services--This modifier shall be used to indicate home health services rendered by other HCPs (e.g., Occupational Therapist, Physical Therapist, Speech Therapist) when the service does not match any other CPT code.

(30) -H5, Home Health Agency Services--This modifier shall be used to indicate home health services rendered by a Home Health Aide

(31) -HE, HE-NE Laser--This modifier shall be used with the "Unlisted modality" CPT code for HE-NE laser treatment.

(32) -ID, Intra Discal Electro Thermal (IDET)--This modifier shall be used with the "Unlisted procedure, nervous system" CPT code when IDET treatment is performed.

(33) -JA, Job Site Analysis/Assessment--This modifier shall be used with the "Unlisted physical medicine/rehabilitation service or procedure" CPT code when a job site visit/assessment is performed.

(34) -ME, Muscle Energy Technique--This modifier shall be used with the "Unlisted therapeutic procedure" CPT code when the muscle energy technique is used for treatment.

(35) -MR, Outpatient Medical Rehabilitation--This modifier shall be used with the "Unlisted physical medicine/rehabilitation service or procedure" CPT code for outpatient medical rehabilitation.

(36) -MT, Muscle Testing--This modifier shall be used with the "Physical performance test or measurement..." CPT code when muscle testing is performed.

(37) -NM, Not at Maximum Medical Improvement (MMI)--This modifier shall be used to indicate that the injured employee has not reached MMI when the purpose of the exam was to determine MMI.

(38) -NP, Nurse Practitioner--This modifier shall be used to indicate a Nurse Practitioner performed an E/M service under the supervision of a doctor. Reimbursement shall be 80% of the MAR.

(39) -OP, One Patient--This modifier shall be used with "physician educational services rendered to patients in a group setting " CPT code to indicate patient education in a one-on-one setting. DOP is required.

(40) -PA, Certified Physician Assistant (PA)--This modifier shall be used to indicate a Certified Physician Assistant performed an E/M service under the supervision of a doctor. Reimbursement shall be 80% of the MAR.

(41) -PH, Phonophoresis--This modifier shall be used with the "Unlisted therapeutic procedure" CPT code when phonophoresis is used for treatment.

(42) -PO, Positional Release--This modifier shall be used with the "Unlisted therapeutic procedure" CPT code when positional release is used for treatment.

(43) -RM, Required Medical Examination--RME not for the purpose of certifying MMI or assessing an impairment rating (IR). This examination is established at the request of the commission or the insurance carrier, modifier "-RM" shall be added to the appropriate consultation CPT code.

(44) -RO, Recovery Room in a Doctor's Office--This modifier shall be added to the "Unlisted evaluation and management service" CPT code for postoperative monitoring services when surgical procedures are performed in the doctor's office.

(45) -RP, Review Report--This modifier shall be added to the "Work related or medical disability examination by the treating physician..." CPT code to indicate that the service was the treating doctor's review of report(s) only.

(46) -RW, Required Return-to-Work Exam--This modifier shall be added to the "Unlisted evaluation and management service" CPT code when a designated doctor is appointed by the commission to perform an examination to resolve return to work disputes.

(47) -R1, Time of MMI/IR for RME Doctor--This modifier shall be added to the "Unlisted evaluation and management service" CPT code when the amount of time that has elapsed since the date of injury is less than one year; or, for any subsequent RMEs.

(48) -R2, Time of MMI/IR for RME Doctor--This modifier shall be added to the "Unlisted evaluation and management service" CPT code when the amount of time that has elapsed since the date of injury is greater than or equal to one year and less than two years.

(49) -R3, Time of MMI/IR for RME Doctor--This modifier shall be added to the "Unlisted evaluation and management service" CPT code when the amount of time that has elapsed since the date of injury is greater than or equal to two years.

(50) -SA, Surgical Assistant--This modifier shall be used when a Certified Physician Assistant (PA) or Certified Surgical Technologist/Certified First Assistant (CST/CFA) perform as the surgical assistant (in lieu of an Assistant Surgeon).

(51) -SS, Spray and Stretch--This modifier shall be used with the "Unlisted therapeutic procedure" CPT code when spraying and stretching is performed.

(52) -ST, Sterile Trays--This modifier shall be added to the "Supplies and materials..." CPT code for sterile trays when surgical procedures are performed in a doctor's office.

(53) -TC, Technical Component--This modifier shall be added to the CPT code when the technical component of a procedure is billed separately.

(54) -TM, Telemedicine--This modifier shall be used with the appropriate E/M CPT code to identify a telemedicine service. Only interactive video teleconferencing shall be reimbursed.

(55) -TN, TENS Application for Trial Basis--This modifier shall be used with the "Unlisted therapeutic procedure" CPT code when TENS application is being performed on a trial basis. This service includes supplies and training.

(56) -TT, Tilt Table--This modifier shall be used with the "Unlisted therapeutic procedure" CPT code when a standing frame tilt table is used for treatment.

(57) -T1, Level of MMI for Treating Doctor--This modifier shall be added to the "Work related or medical disability examination by the treating physician..." CPT code when the office visit level of service is equal to a "minimal" level.

(58) -T2, Level of MMI for Treating Doctor--This modifier shall be added to the "Work related or medical disability examination by the treating physician..." CPT code when the office visit level of service is equal to "self limited or minor" level.

(59) -T3, Level of MMI for Treating Doctor--This modifier shall be added to the "Work related or medical disability examination by the treating physician..." CPT code when the office visit level of service is equal to "low to moderate" level.

(60) -T4, Level of MMI for Treating Doctor--This modifier shall be added to the "Work related or medical disability examination by the treating physician..." CPT code when the office visit level of service is equal to "moderate to high severity" level and of at least 25 minutes duration.

(61) -T5, Level of MMI for Treating Doctor--This modifier shall be added to the "Work related or medical disability examination by the treating physician..." CPT code when the office visit level of service is equal to "moderate to high severity" level and of at least 45 minutes duration.

(62) -VT, Video Tape--This modifier shall be used when a videotape of the fluoroscopic assistance was medically necessary when performing an injection.

(63) -VX, Vertebral Axial Decompression (VAX-D)--This modifier shall be used with the "Unlisted therapeutic procedure" CPT code when performing VAX-D treatment.

(64) -WC, Work Conditioning--This modifier shall be used with the "Work hardening/conditioning" CPT code when work conditioning is performed.

(65) -WH, Work Hardening--This modifier shall be used with the "Work hardening/conditioning" CPT code when work hardening is performed.

(66) -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 HCP.

§134.208.Severability.

Where any terms or sections of this subchapter or its application to any person or circumstance are determined by a court of competent jurisdiction to be invalid, the invalidity does not affect other provisions or applications of this subchapter that can be given effect without the invalidated provision or application.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on June 27, 2001.

TRD-200103677

Susan Cory

General Counsel

Texas Workers' Compensation Commission

Earliest possible date of adoption: August 12, 2001

For further information, please call: (512) 804-4287