Mississippi Administrative Code › Title 20 - Labor › Part 2 - Mississippi Workers' Compensation Medical Fee Schedule › INTRODUCTION › Section 20-2-IV - DEFINITIONS

Current through June 25, 2024
Act
means Mississippi Workers' Compensation Law,
				  Mississippi Code Annotated (MCA), §
									71-3-1
				  et seq (Rev. 2000 as amended).
Adjust
means that a payer or a payer's agent
				  reduces or otherwise alters a health care provider's request for payment.
APC
means ambulatory payment classification and
				  guidelines for hospital outpatient and ambulatory surgery center facilities as
				  developed by the Centers for Medicare and Medicaid Services (CMS) and adopted
				  in this Fee Schedule.
Appropriate care
means health care that is
				  suitable for a particular patient, condition, occasion, or place.
AWP
means Average Wholesale Price; and is based
				  on data obtained from manufacturers.
Bill
means a claim submitted by a provider to a
				  payer for payment of health care services provided in connection with a covered
				  injury or illness.
Bill adjustment
means a reduction of a fee on a
				  provider's bill, or other alteration of a provider's bill.
By report (BR)
means that the procedure is new,
				  or is not assigned a maximum fee, and requires a written description included
				  on or attached to the bill. "By report" (BR) procedures require a complete
				  listing/description of the service, the dates of service, the procedure code,
				  and the payment requested. The report is included in the request for
				  reimbursement for the procedure.
Carrier
means any stock company, mutual company,
				  or reciprocal or inter-insurance exchange authorized to write or carry on the
				  business of Workers' Compensation Insurance in this State, or self-insured
				  group, or third-party payer, or self-insured employer, or uninsured
				  employer.
CARF
, the Commission on Accreditation of
				  Rehabilitation Facilities, is an independent, nonprofit accreditor of health
				  and human services such as medical rehabilitation facilities.
Case
means a covered injury or illness occurring
				  on a specific date and identified by the worker's name and date of injury or
				  illness.
CDT
means Current Dental Terminology, a medical
				  code set maintained and copyrighted by the American Dental Association, which
				  is used for reporting dental services.
CMS-1500
means the CMS-1500 form and
				  instructions that are used by non-institutional providers and suppliers to bill
				  for outpatient services. Use of the most current CMS-1500 form is required.
Commission
means the Mississippi Workers'
				  Compensation Commission (MWCC).
Consultation
means a service provided by a
				  physician whose opinion or advice regarding evaluation and/or management of a
				  specific problem is requested by another physician or other appropriate source.
				  If a consultant, subsequent to the first encounter, assumes responsibility for
				  management of the patient's condition, that physician becomes a treating
				  physician. The first encounter is a consultation and shall be billed and
				  reimbursed as such. A consultant shall provide a written report of his/her
				  findings.
A second opinion is considered a consultation.
Controverted claim
is a workers' compensation
				  claim which is pending before the MWCC and in which the patient or patient's
				  legal representative has filed a Petition to Controvert.
Covered injury or illness
means an injury or
				  illness for which treatment is mandated under the Act.
Critical care
means care rendered in a variety
				  of medical emergencies that requires the constant attention of the
				  practitioner, such as cardiac arrest, shock, bleeding, respiratory failure,
				  postoperative complications, and is usually provided in a critical care unit or
				  an emergency department.
CPT (Current Procedural Terminology)
means a set
				  of codes, descriptions, and guidelines developed by the American Medical
				  Association, intended to describe procedures and services performed by
				  physicians and other health care professionals. The CPT code set is also used
				  by other entities to report outpatient services. Each procedure or service is
				  identified with a five-digit code. CPT codes may also be referred to as HCPCS
				  Level I codes.
Day
means a continuous 24-hour period.
Diagnostic
procedure means a service that helps
				  determine the nature and causes of a disease or injury.
Durable medical equipment (DME)
means
				  specialized equipment designed to stand repeated use, appropriate for home use,
				  and used solely for medical purposes.
Employer Medical Evaluation (EME)
means a second
				  opinion evaluation available to the Employer or Carrier pursuant to MCA §
									71-3-15(1)
				  (Rev. 2000) for the purpose of evaluating temporary or permanent disability, or
				  the medical treatment being rendered to the injured worker.
Expendable medical supply
means a disposable
				  article that is needed in quantity on a daily or monthly basis.
Follow-up care
means the care which is related
				  to the recovery from a specific procedure and which is considered part of the
				  procedure's maximum allowable reimbursement, but does not include
				  complications.
Follow-up days (FUD)
are the days of care
				  following a surgical procedure which are included in the procedure's maximum
				  allowable reimbursement amount, but which do not include follow up care related
				  to complications. The follow-up day period begins on the day of the surgical
				  procedure(s).
HCPCS
means Healthcare Common Procedure Coding
				  System, an alpha-numeric medical code set maintained by the Centers for
				  Medicare and Medicaid Services used for reporting services, durable medical
				  equipment, and supplies. CPT codes are Level I HCPCS codes. HCPCS codes may
				  also be referred to as HCPCS Level II codes.
Health care review
means the review of a health
				  care case, bill, or both by the payer or the payer's agent.
Incident - to
means that services and supplies
				  are commonly furnished as an integral part of the primary service or procedure
				  and not reimbursed separately.
Incidental surgery
means surgery performed
				  through the same incision, on the same day, by the same doctor, not increasing
				  the difficulty or follow-up of the main procedure, or not related to the
				  diagnosis.
Independent medical examination (IME)
means a
				  consultation provided by a physician to evaluate a patient at the request of
				  the MWCC. This evaluation may include an extensive record review and physical
				  examination of the patient and requires a written report.
Independent procedure
means a procedure that may
				  be carried out by itself, completely separate and apart from the total service
				  that usually accompanies it.
Inpatient services
means services rendered to a
				  person who is admitted to a hospital as an inpatient.
MAR
(See Maximum allowable reimbursement)
Maximum allowable reimbursement (MAR)
means the
				  maximum amount allowed for medical services as set forth in this Fee
				  Schedule.
Medical only case
means a case that does not
				  involve more than five (5) days of disability or lost work time and for which
				  only medical treatment is required.
Medically accepted standard
means a measure set
				  by a competent authority as the rule for evaluating quality or quantity of
				  health care or health care services and which may be defined in relation to any
				  of the following:
* Professional performance;
* Professional credentials;
* The actual or predicted effects of care; and
* The range of variation from the norm.
MWCC
means the Mississippi Workers' Compensation
				  Commission.
Medically necessary
means any reasonable medical
				  service or supply used to identify or treat a work-related injury/illness which
				  is appropriate to the patient's diagnosis, is based upon accepted standards of
				  the health care specialty involved, represents an appropriate level of care
				  given the location of service, the nature and seriousness of the condition, and
				  the frequency and duration of services, is not experimental or investigational,
				  and is consistent with or comparable to the treatment of like or similar
				  non-work related injuries. Utilization management or review decisions shall not
				  be based on application of clinical guidelines, but must include review of
				  clinical information submitted by the provider and represent an individualized
				  determination based on the worker's current condition and the concept of
				  medical necessity predicated on objective or appropriate subjective
				  improvements in the patient's clinical status.
Medical record
means a record in which the
				  medical service provider records the subjective findings, objective findings,
				  diagnosis, treatment rendered, treatment plan, and return to work status and/or
				  goals and impairment rating as applicable.
Medical supply
means either a piece of durable
				  medical equipment or an expendable medical supply.
National Correct Coding Initiative (NCCI)
means
				  an initiative implemented by the Centers for Medicare and Medicaid Services'
				  (CMS) to promote national correct coding methodologies and to control improper
				  coding leading to inappropriate payment. NCCI Procedure-to-Procedure (PTP) code
				  pair edits are automated prepayment edits that prevent improper payment when
				  certain codes are submitted together. Medically Unlikely Edits (MUEs) are the
				  maximum number of Units of Service (UOS) allowable under most circumstances for
				  a single Healthcare Common Procedure Coding System/Current Procedural
				  Terminology (HCPCS/CPT) code billed by a provider on a date of service.
NCCI
(See National Correct Coding
				  Initiative.)
Observation
care is a well-defined set of
				  specific, clinically appropriate services, which include ongoing short term
				  treatment, assessment, and reassessment before a decision can be made regarding
				  whether patients will require further treatment as hospital inpatients or if
				  they are able to be discharged from the hospital..
Operative report
means the practitioner's
				  written description of the surgery or procedure and includes all of the
				  following:
* A preoperative diagnosis;
* A postoperative diagnosis;
* A step-by-step description of the surgery;
* A description of any problems that occurred in surgery; and
* The condition of the patient upon leaving the operating
				  room.
Optometrist
means an individual licensed to
				  practice optometry.
Orthotic equipment
means an orthopedic apparatus
				  designed to support, align, prevent, or correct deformities, or improve the
				  function of a moveable body part.
Orthotist
means a person skilled in the
				  construction and application of orthotic equipment.
Outpatient service
means services provided to
				  patients at a time when they are not hospitalized as inpatients.
Payer
means the employer or self-insured group,
				  carrier, or third-party administrator (TPA) who pays the provider
				  billings.
Pharmacy
means the place where the science, art,
				  and practice of preparing, preserving, compounding, dispensing, and giving
				  appropriate instruction in the use of drugs is practiced.
Practitioner
means a person licensed,
				  registered, or certified as an acupuncturist, audiologist, doctor of
				  chiropractic, doctor of dental surgery, doctor of medicine, doctor of
				  osteopathy, doctor of podiatry, doctor of optometry, massage therapist, nurse,
				  nurse anesthetist, nurse practitioner, occupational therapist, orthotist,
				  pharmacist, physical therapist, physician assistant, prosthetist, psychologist,
				  or other person licensed, registered, or certified as a health care
				  professional or provider.
Primary procedure
means the therapeutic
				  procedure most closely related to the principal diagnosis, and in billing, the
				  code with the highest unit that is neither an add-on code nor a code exempt
				  from modifier 51 shall be considered the primary procedure. Reimbursement for
				  the primary procedure is not dependent on the ordering or re-ordering of
				  codes.
Procedure
means a unit of health service.
Procedure code
means a five-digit numerical
				  sequence or a sequence containing an alpha character and preceded or followed
				  by four digits, which identifies the service performed and billed.
Properly submitted bill
means a request by a
				  provider for payment of health care services submitted to a payer on the
				  appropriate forms with appropriate documentation and within the time frame
				  established under the guidelines of the Fee Schedule.
Prosthesis
means an artificial substitute for a
				  missing body part.
Prosthetist
means a person skilled in the
				  construction and application of prostheses.
Provider
means a facility, health care
				  organization, or a practitioner who provides medical care or services.
Secondary procedure
means a surgical procedure
				  performed during the same operative session as the primary surgery but
				  considered an independent procedure that may not be performed as part of the
				  primary surgery.
Special report
means a report requested by the
				  payer to explain or substantiate a service or clarify a diagnosis or treatment
				  plan.
Specialist
means a board-certified practitioner,
				  board-eligible practitioner, or a practitioner otherwise considered an expert
				  in a particular field of health care service by virtue of education, training,
				  and experience generally accepted by practitioners in that particular field of
				  health care service.
Usual and customary
means that when a payment is
				  designated herein as "usual and customary," the amount of the payment equates
				  to the charge value reported by FAIR Health, Inc. in its FH Benchmarks (or
				  other FAIR Health, Inc. Benchmark product available on the date of service)
				  products at the 40th percentile for the applicable geographic area in
				  Mississippi.