reglab/statecodes huggingface dataset:
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 1 - GENERAL PROVISIONS › Section R. 418.10118 - Practitioner, facility, and health care organization copying charge for medical records

Current through Vol. 24-12, July 15, 2024
Rule 118.
(1) A
				  practitioner, facility, or health care organization shall, at the request of
				  the carrier, the carrier's agent, the employee, or the employee's agent,
				  furnish copies of the case record for a particular covered injury or illness to
				  the carrier, the carrier's agent, the employee, or the employee's agent. The
				  maximum fee for providing copies shall be 45 cents per page, plus the actual
				  cost of mailing. In addition, an administration charge for the staff's time to
				  retrieve and copy the records shall be paid as follows: 0-15 minutes $2.50 Each
				  additional 15 minute increment $2.50 The copying and handling charge shall
				  apply to all reports and records, other than the original copy required
				  pursuant to the provisions of
				  R 418.10113, and all other reports
				  required by these rules. The party who requests the records shall pay the
				  copying charge.
(2) The copying
				  charge for each x-ray film requested by the carrier or the carrier's agent
				  shall be reimbursed at $15.00, which includes mailing and handling.
(3) If an agent of a carrier or an employee
				  requests a copy of the case record, then the agent shall indicate the date of
				  injury. Only the records for a specific date of injury covered by the act and
				  these rules are available as specified in subrule (1) of this rule.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 1 - GENERAL PROVISIONS › Section R. 418.10120 - Recovery of payment

Current through Vol. 24-12, July 15, 2024
Rule 120.
(1)
				  Nothing in this rule shall preclude the recovery of payment for services and
				  bills which may later be found to have been medically inappropriate or paid at
				  an amount that is more than the maximum allowable payment.
(2) If the carrier makes a request to the
				  provider for the recovery of a payment within 1 year of the date of payment and
				  includes a statement of the reasons for the request, then the carrier may
				  recover a payment. The carrier may recover a payment made by an employee or the
				  carrier.
(3) Within 30 days of
				  receipt of the carrier's request for recovery of the payment, the provider
				  shall do either of the following:
(a) If the
				  provider is in agreement with the request, then the provider shall refund the
				  payment to the carrier.
(b) If the
				  provider is not in agreement with the request, then the provider shall supply
				  the carrier with a written detailed statement of the reasons for its
				  disagreement, together with a refund of the portion, if any, of the payment
				  that the provider agrees should be refunded.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 1 - GENERAL PROVISIONS › Section R. 418.10121 - Rehabilitation nurse or nurse case manager visits; additional services

Current through Vol. 24-12, July 15, 2024
Rule 121.
(1) If a
				  carrier assigns a rehabilitation nurse or nurse case manager to an injured
				  worker's case, and the carrier requires that the nurse accompany the injured
				  worker to provider visits, then the carrier shall reimburse the provider for
				  the additional time.
(2) The
				  provider may bill the rehabilitation nurse or nurse case manager visit in
				  addition to the evaluation and management service using code RN001. The carrier
				  shall reimburse the provider $25.00 for RN001.
(3) Procedure code RN001 shall be reimbursed
				  at the maximum allowable fee if the provider bills the procedure during the
				  global period for a surgical service.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 2 - MEDICINE › Section R. 418.10203 - Office visit or other outpatient visit for evaluation and management of patient in conjunction with ongoing osteopathic manipulative treatment or chiropractic manipulative treatment

Current through Vol. 24-12, July 15, 2024
Rule 203.
(1) The
				  carrier shall reimburse for the initial evaluation and management examination
				  billed by the provider before initiating chiropractic or osteopathic
				  manipulation. The carrier shall also reimburse for osteopathic manipulative
				  treatment or chiropractic manipulative treatment if the treatment is initiated
				  on the same date of service.
(2)
				  All of the following provisions apply to ongoing osteopathic manipulative
				  treatment:
(a) Osteopathic manipulative
				  treatment procedure codes include pre-manipulative patient evaluation. The
				  physician may bill a separate evaluation and management service using modifier
				  code -25. The carrier shall only reimburse the service if the documentation
				  provided supports significant change of signs and symptoms or the evaluation of
				  another work related problem not included in the procedure or service that
				  required the encounter. The physician shall document the rationale for the
				  significant other service in the record.
(b) Osteopathic manipulations are to be
				  billed using procedure codes 98925-98929.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 2 - MEDICINE › Section R. 418.10204 - Office visit or other outpatient visit; evaluation and management of patient's progress in physical treatment

Current through Vol. 24-12, July 15, 2024
Rule 204.
(1) An
				  office visit or other outpatient visit for the evaluation and management of a
				  patient's progress in physical treatment shall only be billed when there is a
				  change of signs or symptoms and when the referring or treating practitioner
				  provides supporting documentation as described in subrule (2) of this rule. The
				  supporting documentation shall indicate that it is medically appropriate for
				  the practitioner to make the evaluation.
(2) Documentation shall include the referring
				  or treating practitioner's statement that an office visit was medically
				  necessary. In addition, a report shall state that an examination was conducted
				  and shall set forth the specific findings by the practitioner, including all of
				  the following:
(a) A description of the
				  evaluation of function in measurable terms based on physical findings and
				  problem identification.
(b) A goal
				  statement.
(c) A treatment
				  plan.
(d) Physical and functional
				  improvement in measurable terms that has occurred in relationship to the
				  diagnosis for which physical medicine treatment was prescribed.
(e) The likelihood of continued improvement
				  if physical medicine treatment were continued.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 2 - MEDICINE › Section R. 418.10205 - Consultation services

Current through Vol. 24-12, July 15, 2024
Rule 205.
(1) An
				  attending physician, carrier, third-party administrator, or the injured worker
				  may request a consultation. Codes 99241-99245 and 99251-99255 shall not be used
				  for consultation examinations. Providers shall use the evaluation code that
				  most accurately reflects the service rendered.
(2) If a specialist performs diagnostic
				  procedures or testing in addition to the evaluation, then the specialist shall
				  bill the appropriate procedure code from "Physicians' Current Procedural
				  Terminology (CPT[R]). The carrier shall reimburse the testing procedures in
				  accordance with these rules.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 2 - MEDICINE › Section R. 418.10207 - Mental health services

Current through Vol. 24-12, July 15, 2024
Rule 207.
(1) A
				  psychiatrist only, shall use procedure code 90792 to describe a psychiatric
				  diagnostic evaluation with medical services, or shall use a new patient
				  evaluation and management code instead of 90792 to describe a psychiatric
				  diagnostic evaluation. A psychologist shall use procedure code 90791 to
				  describe a diagnostic evaluation without medical services. Procedure codes
				  90791 and 90792 shall not be reported on the same day as a psychotherapy or
				  evaluation and management service procedure code.
(2) A psychiatrist only, shall use add on
				  procedure codes 90833, 90836 and 90838, which shall be reported in conjunction
				  with an evaluation and management services code.
(3) An individual performing psychological
				  testing shall report the services using procedure codes 96105-96146.
(4) Mental health providers shall use the
				  following modifiers to describe the practitioner providing the health services:
(a) -AH, for services provided by a licensed
				  psychologist.
(b) -AL, for services
				  provided by a limited licensed psychologist.
(c) -AJ, for services provided by a certified
				  social worker.
(d) -LC, for
				  services provided by a licensed professional counselor.
(e) -CS, for services provided by a limited
				  licensed counselor.
(f) -MF, for
				  services provided by a licensed marriage and family therapist.
(g) -ML, for services provided by a limited
				  licensed marriage and family therapist
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 2 - MEDICINE › Section R. 418.10208 - Vision services

Current through Vol. 24-12, July 15, 2024
Rule 208.
(1) A
				  medical diagnostic eye evaluation by a practitioner is an integral part of all
				  vision services.
(2) Intermediate
				  and comprehensive ophthalmological services include medical diagnostic eye
				  evaluation and services, such as slit lamp examination, keratometry,
				  ophthalmoscopy, retinoscopy, tonometry, or motor evaluation. These procedures
				  shall not be billed in conjunction with procedure codes 92002, 92004, 92012,
				  and 92014.
(3) Only an
				  ophthalmologist or a doctor of optometry shall use procedure codes 92002,
				  92004, 92012, and 92014.
(4) An
				  employer is not required to reimburse or cause to be reimbursed charges for an
				  optometric service unless that service is included in the definition of
				  practice of optometry under section 17401 of the public health code, 1978 PA
				  368, MCL 333.17401, as of May 20, 1992.
(5) Suppliers of vision and prosthetic
				  optical procedures shall use the appropriate procedure code V0000-V2999 listed
				  in the HCPCS Level II codebook, as adopted by reference in 418.10107, to
				  describe services provided.
(6)
				  Payment shall be made as follows for the following vision CPT codes:
(a) $50.00 for V2744, V2750, and
				  V2760.
(b) $25.00 for
				  V2715.
(c) $160.00 for
				  V2020.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 2 - MEDICINE › Section R. 418.10209 - Hearing services

Current through Vol. 24-12, July 15, 2024
Rule 209.
(1) A
				  provider performing a comprehensive otorhinolaryngologic evaluation shall
				  report the service using the appropriate evaluation and management
				  service.
(2) A provider shall not
				  report an otoscope
,
a rhinoscopy
,
or a tuning fork
				  test in addition to a comprehensive ear evaluation or office visit.
(3) A provider performing special
				  otorhinolaryngologic procedures, in addition to the evaluation, shall report
				  those services using procedure codes 92502-92700.
(4) An audiologist, speech therapist, and a
				  speech and hearing center shall use appropriate procedure codes from "Current
				  Procedural Terminology, (CPT&reg)" or the HCPCS Level II codebook, as
				  adopted by reference in
				  R 418.10107, to describe services
				  provided.
(5) Hearing aid suppliers
				  shall use the appropriate procedure code listed in the HCPCS Level II codebook,
				  as adopted by reference in
				  R 418.10107 to describe services
				  provided.
(6) When requesting
				  payment for hearing aids a minimum of 2 comparable written quotations shall be
				  required for hearing aids that exceed $1,500 per hearing aid, including related
				  services such as orientation, fitting, ear molds, support, adjustment,
				  conformity check, batteries, warranties and follow-up. Only a single price
				  quotation shall be required for hearing aids, including related services, that
				  cost $1,500 or less per hearing aid.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 2 - MEDICINE › Section R. 418.10212 - Physical and occupational therapy; physical medicine services ; physical treatment

Current through Vol. 24-12, July 15, 2024
Rule 212.
(1) For
				  the purposes of workers' compensation, physical medicine services, procedure
				  codes 97010-97799, shall be referred to as "physical treatment" when the
				  services are provided by a practitioner other than a physical therapist or an
				  occupational therapist. Physical therapy means physical treatment provided by a
				  licensed physical therapist. Occupational therapy means physical treatment
				  provided by an occupational therapist.
(2) Physical medicine services shall be
				  restorative. If documentation does not support the restorative nature of the
				  treatment, then the service shall not be reimbursed.
(3) Any of the following may provide physical
				  treatment, to the extent that licensure, registration, or certification law
				  allows:
(a) A doctor of medicine.
(b) A doctor of osteopathic medicine and
				  surgery.
(c) A doctor of dental
				  surgery.
(d) A doctor of
				  chiropractic.
(e) A doctor of
				  podiatric medicine and surgery.
(f)
				  A physical therapist.
(g) An
				  occupational therapist.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 2 - MEDICINE › Section R. 418.10214 - Orthotic and prosthetic equipment

Current through Vol. 24-12, July 15, 2024
Rule 214.
(1) A
				  copy of a prescription by 1 of the following is required for prosthetic and
				  orthotic equipment:
(a) A doctor of
				  medicine.
(b) A doctor of
				  osteopathic medicine and surgery.
(c) A doctor of chiropractic.
(d) A doctor of podiatric medicine and
				  surgery.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 4 - SURGERY › Section R. 418.10401 - Global surgical procedure; services included

Current through Vol. 24-12, July 15, 2024
Rule 401.
(1) The
				  surgical procedures in the CPT code set as adopted in
				  R 418.10107 always include the
				  following list of specific services in addition to the surgical procedure.
(a) Local infiltration,
				  metacarpal/metatarsal/digital block or topical anesthesia.
(b) Subsequent to the decision for surgery, 1
				  related evaluation and management encounter on the date immediately prior to or
				  on the date of the procedure is included. However, when an initial evaluation
				  and management encounter occurs and a decision for surgery is made at that
				  encounter, the evaluation and management service is payable in addition to the
				  surgical procedure.
(c) Immediate
				  postoperative care, including dictating operative notes, talking with the
				  family and other physicians.
(d)
				  Writing postoperative surgical orders in the patient's chart and dictating an
				  operative report.
(e) Evaluating
				  the patient in the postanesthesia recovery area.
(f) Typical, routine, normal postoperative
				  follow-up care, including suture removal, during the global period. The global
				  period or follow-up days shall be provided separate from the rules on the
				  agency website,
www.michigan.gov/wca
.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 4 - SURGERY › Section R. 418.10403 - Complication, exacerbation, recurrence, or presence of other disease or injury

Current through Vol. 24-12, July 15, 2024
Rule 403.
(1) If a
				  complication, exacerbation, recurrence, or the presence of other disease or
				  injury exists that requires additional services, then the services shall be
				  reported and identified by the appropriate procedure code.
(2) Reimbursement shall only be made for
				  services related to, or resulting from, the covered work injury.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 4 - SURGERY › Section R. 418.10404 - Follow-up care occurring during global service

Current through Vol. 24-12, July 15, 2024
Rule 404.
(1)
				  Follow-up care for a diagnostic procedure shall refer only to the days required
				  to recover from the diagnostic procedure and not the treatment of the
				  underlying condition.
(2) Follow-up
				  care for therapeutic surgical procedures includes only that care that is
				  usually part of the surgical service. Complications, exacerbations, recurrence,
				  or the presence of other compensable diseases or injuries requiring additional
				  services should be reported with the identification of appropriate procedures.
				  The follow-up days for the surgical procedures are adopted from the "Medicare
				  RBRVS: The Physicians Guide," as referenced in
				  R 418.10107. The follow-up days for
				  each surgical procedure are provided separate from these rules on the agency
				  website,
www.michigan.gov/wca
.
				  All of the following apply to the global service provider:
(a) If a carrier requests the surgeon to see
				  an injured worker during the global service period for the purpose of job
				  restrictions, job adjustments, or return to work, then the visit shall not be
				  considered part of the global surgery package. If the carrier requests the
				  visit, then the carrier shall prior authorize the visit assigning an
				  authorization number. The provider shall bill the visit using procedure 99455
				  and modifier -32, including the authorization number in box 23 of the CMS 1500
				  form. The carrier shall not deny a prior authorized visit and shall reimburse
				  the provider for the prior authorized visit. The maximum allowable payment for
				  99455-32 shall be listed in the manual published separate from these
				  rules.
(b) The medical record shall
				  reflect job adjustments, job restrictions or limitations, or return to work
				  date, and the provider shall include the medical record with the
				  bill.
(c) If an insured employer
				  requests the surgeon to see an injured worker during the global surgery period
				  for the purpose of job adjustments, restrictions, or return to work, then the
				  employer shall obtain the prior authorization number from the carrier for the
				  visit.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 4 - SURGERY › Section R. 418.10410 - Incidental surgeries

Current through Vol. 24-12, July 15, 2024
Rule 410. The carrier shall not pay a bill for an
					 incidental surgery which is not part of the primary procedure performed, and
					 for which there is no diagnostic evidence or relationship to the covered work
					 injury.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 4 - SURGERY › Section R. 418.10416 - Assistant surgeon

Current through Vol. 24-12, July 15, 2024
Rule 416.
(1) The
				  carrier shall reimburse for an assistant surgeon service for those surgical
				  procedures designated by CMS as allowing additional reimbursement for a
				  surgical assistant. The surgical procedures allowing reimbursement for an
				  assistant surgeon shall be provided separate from these rules on the agency
				  website,
www.michigan.gov/wca
.
(2) Any of the following may bill assistant
				  surgeon services using modifier -80:
(a) A
				  doctor of dental surgery.
(b) A
				  doctor of osteopathy.
(c) A doctor
				  of medicine.
(d) A doctor of
				  podiatry.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 4 - SURGERY › Section R. 418.10417 - Ophthalmological surgical procedures

Current through Vol. 24-12, July 15, 2024
Rule 417. Ophthalmological surgical procedure codes for the
					 removal of a foreign body include topical anesthesia, fluorescein staining, and
					 lavage.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 5 - RADIOLOGY, RADIATION THERAPY, AND NUCLEAR MEDICINE › Section R. 418.10504 - Multiple procedure policy for radiology procedures

Current through Vol. 24-12, July 15, 2024
Rule 504.
(1) A
				  multiple procedure payment reduction shall apply to specified radiology
				  procedures when performed in a freestanding radiology office, a non-hospital
				  facility, or a physician's office or clinic. The primary procedure, identified
				  by the code with the highest relative value, shall be paid at 100% of the
				  maximum allowable payment. If the provider's charge is less than the maximum
				  allowable payment, then the service shall be paid at 100% of the provider's
				  charge.
(2) The multiple procedure
				  payment reduction shall apply when multiple radiological diagnostic imaging
				  procedures are furnished to the same patient, on the same day, in the same
				  session, by the same physician or group practice that has the same national
				  provider identifier. The agency shall publish in a manual separate from these
				  rules a table listing the diagnostic imaging CPT codes subject to the multiple
				  procedure payment reduction. When more than 1 procedure from the table is
				  furnished to the same patient, on the same day, in the same session, by the
				  same physician or group practice, the procedure with the highest relative value
				  is paid at 100% of the maximum allowable payment. Each additional procedure
				  shall have modifier -51 appended and the technical component shall be reduced
				  to 50% of the maximum allowable payment, or the provider's charge, whichever is
				  less, and the professional component shall be reduced to 75% of the maximum
				  allowable payment, or the provider's charge, whichever is less.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 5 - RADIOLOGY, RADIATION THERAPY, AND NUCLEAR MEDICINE › Section R. 418.10505 - Multiple procedure policy for specific nuclear medicine procedures

Current through Vol. 24-12, July 15, 2024
Rule 505.
(1) The
				  multiple procedure reduction and the use of modifier -51 shall apply to the
				  complete procedure, the technical component, and the professional component,
				  when multiples of the following nuclear medicine diagnostic procedure codes are
				  performed: 78306, 78320, 78802, 78803, 78806, and 78807.
(2) When the procedures listed in subrule (1)
				  of this rule are performed in a hospital setting, the hospital is reimbursed by
				  the cost-to-charge methodology and the multiple payment rule shall apply to the
				  professional component billed by the radiologist.
(3) When the services are performed in an
				  office, clinic, or freestanding radiology office, the reduction shall be
				  applied to the complete procedure.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 7 - DENTAL › Section R. 418.10701 - Scope

Current through Vol. 24-12, July 15, 2024
Rule 701.
(1)
				  Dental services, related to, or resulting from, a covered work-related injury
				  are covered under these rules. Incidental dental services are not
				  covered.
(2) A dental provider
				  shall bill services on a standard American dental claim form. The workers'
				  compensation agency shall provide a copy of the claim form and instructions for
				  completion separate from these rules in the health care services manual on the
				  agency's website at
www.michigan.gov/wca
.
(3) Dental services shall be reimbursed at
				  either the dentist's usual and customary fee or reasonable fee, whichever is
				  less.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 9 - BILLING › Subpart A - PRACTITIONER BILLING › Section R. 418.10901 - General information

Current through Vol. 24-12, July 15, 2024
Rule 901.
(1)
					 All health care practitioners and health care organizations, as defined in
					 these rules, shall submit charges on the proper claim form as specified in this
					 rule. Copies of the claim forms and instruction for completion for each form
					 shall be provided separate from these rules in a manual on the workers'
					 compensation agency's website at
www.michigan.gov/wca
. Charges shall be
					 submitted as follows:
(a) A practitioner shall
					 submit charges on the CMS1500 claim form.
(b) A doctor of dentistry shall submit
					 charges on a standard dental claim form approved by the American Dental
					 Association.
(c) A pharmacy, other
					 than an inpatient hospital, shall submit charges on an invoice or an NCPDP
					 Workers Compensation/Property & Casualty Universal Claim Form.
(d) A hospital-owned occupational or
					 industrial clinic, or office practice shall submit charges on the CMS 1500
					 claim form.
(e) A hospital billing
					 for a practitioner service shall submit charges on a CMS 1500 claim
					 form.
(f) Ancillary service charges
					 shall be submitted on the CMS 1500 claim form for durable medical equipment and
					 supplies, L-code procedures, ambulance, vision, and hearing services. Charges
					 for home health services shall be submitted on the UB-04 claim form.
(g) A shoe supplier or wig supplier shall
					 submit charges on an invoice.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 9 - BILLING › Subpart A - PRACTITIONER BILLING › Section R. 418.10902 - Billing for injectable medications, other than vaccines and toxoids, in office setting

Current through Vol. 24-12, July 15, 2024
Rule 902.
(1)
					 The provider shall not bill the carrier for administration of therapeutic
					 injections when billing an evaluation and management procedure code. If an
					 evaluation and management procedure code is not listed, then the appropriate
					 medication administration procedure code may be billed.
(2) The medication being administered shall
					 be billed with either the unlisted drug and supply code from the CPT code set
					 or the specific J-code procedure from the HCPCS Level II codebook, as adopted
					 by reference in
					 R 418.10107.
(3) The provider shall list the NDC number
					 for the medication in the upper shaded portion of box 24 of the CMS
					 1500.
(4) The carrier shall
					 reimburse the medication at average wholesale price (AWP) minus 10%, as
					 determined by Red Book or Medi-Span, as adopted by reference in
					 R 418.10107. No dispense fee shall
					 be billed for injectable medications administered in the office
					 setting.
(5) If the provider does
					 not list the national drug code for the medication, the carrier shall reimburse
					 the medication using the least costly NDC number by Red Book or Medi-Span for
					 that medication.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 9 - BILLING › Subpart A - PRACTITIONER BILLING › Section R. 418.10902a - Billing for vaccines and toxoids in office setting

Current through Vol. 24-12, July 15, 2024
Rule 902a.
(1)
					 When a provider administers a vaccine or toxoid in the office setting, both the
					 vaccine and toxoid shall be billed as separate services. If a significantly
					 separate evaluation and management service is performed, the appropriate
					 evaluation and management service code shall be reported in addition to the
					 vaccine or toxoid administration code pursuant to CPT codebook guidelines, as
					 adopted by reference in
					 R 418.10107.
(2) The vaccine or toxoid being administered
					 and the administration of the vaccine or toxoid shall be billed using the
					 applicable CPT procedure codes pursuant to CPT codebook guidelines, as adopted
					 by reference in
					 R 418.10107.
(3) The provider shall list the NDC number
					 for the vaccine or toxoid in the upper shaded portion of box 24 of the CMS
					 1500.
(4) The carrier shall
					 reimburse the vaccine or toxoid at the average wholesale price (AWP) minus 10%,
					 as determined by Red Book or Medi-Span, as adopted by reference in
					 R 418.10107. No dispensing fee
					 shall be billed for vaccines or toxoids administered in the office
					 setting.
(5) If the provider does
					 not list the NDC number for the vaccine or toxoid, the carrier shall reimburse
					 the vaccine or toxoid using the least costly NDC number listed by Red Book or
					 Medi-Span for that vaccine or toxoid.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 9 - BILLING › Subpart A - PRACTITIONER BILLING › Section R. 418.10904 - Procedure codes and modifiers

Current through Vol. 24-12, July 15, 2024
Rule 904.
(1) A
					 healthcare service must be billed with procedure codes adopted from "Current
					 Procedural Terminology (CPT) 2023 Professional Edition" or "HCPCS 2023 Level II
					 Professional Edition," as referenced in
					 R 418.10107. Procedure codes from
					 the CPT code set are not included in these rules, but are provided on the
					 agency's website at
www.michigan.gov/leo/bureaus-agencies/wdca
.
					 Refer to "Current Procedural Terminology (CPT) 2023 Professional Edition," as
					 referenced in R 418.10107,
					 for standard billing instructions, except where otherwise noted in these rules.
					 A provider billing services described with procedure codes from "HCPCS 2023
					 Level II Professional Edition" shall refer to the publication as adopted by
					 reference in R 418.10107,
					 for coding information.
(2) The
					 following ancillary service providers shall bill codes from "HCPCS 2023 Level
					 II Professional Edition," as adopted by reference in
					 R 418.10107, to describe the
					 ancillary services:
(a) Ambulance
					 providers.
(b) Certified orthotists
					 and prosthetists.
(c) Medical
					 suppliers, including expendable and durable equipment.
(d) Hearing aid vendors and suppliers of
					 prosthetic eye equipment.
(e) A
					 home health agency.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 9 - BILLING › Subpart A - PRACTITIONER BILLING › Section R. 418.10905 - Billing for physical and occupational therapy

Current through Vol. 24-12, July 15, 2024
Rule 905.
(1) A
					 physical or occupational therapist shall bill procedure codes 97010-97799. A
					 licensed occupational therapist or licensed physical therapist in independent
					 practice shall place his or her signature and license or certification number
					 on the bill.
(2) Only a physician,
					 licensed occupational therapist or a licensed physical therapist shall bill for
					 job site evaluation or treatment. The reimbursement for these procedures shall
					 be contractual between the carrier and provider and shall be billed as listed
					 in the following table: Code Descriptor WC500 Job site evaluation; patient
					 specific, initial 60 minutes WC505 each additional 30 minutes, by contractual
					 agreement WC550 Job site treatment; patient specific, initial 60 minutes WC555
					 each additional 30 minutes, by contractual agreement WC600 Mileage for job site
					 evaluation or job site treatment per mile.
(3) Procedures 97760 and 97761 shall only be
					 reimbursed when billed by a licensed occupational or licensed physical
					 therapist.
(4) Only a licensed
					 physical or occupational therapist shall bill for work hardening services, "by
					 report" or "BR," procedure codes 97545 and 97546.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 9 - BILLING › Subpart A - PRACTITIONER BILLING › Section R. 418.10909 - Billing for home health services

Current through Vol. 24-12, July 15, 2024
Rule 909.
(1)
					 Services provided by a home health agency are considered ancillary services
					 requiring a written prescription by a licensed practitioner certifying medical
					 necessity. A copy of the prescription shall be attached to the bill.
(2) A home health agency shall submit charges
					 to the workers' compensation carrier using the UB-04 claim form.
(3) A home health agency shall use procedure
					 codes from the HCPCS Level II codebook, as adopted by reference in
					 R 418.10107 to identify services
					 provided.
(4) A home health agency
					 shall not bill for the services of a social worker unless the certified social
					 worker is providing medically necessary therapeutic counseling.
(5) A home health agency may bill supplies
					 with 99070, the unlisted CPT code for miscellaneous supplies, or the
					 appropriate supply code from the HCPCS Level II codebook as adopted by
					 reference in
					 R 418.10107.
(6) When a procedure code is described by the
					 HCPCS Level II codebook as per diem, the "by report" service is reimbursed per
					 visit. When the HCPCS Level II codebook describes a service as time-based the
					 service is "by report," and the procedure is reimbursed according to the time
					 provided.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 9 - BILLING › Subpart A - PRACTITIONER BILLING › Section R. 418.10911 - Billing requirements for ancillary services

Current through Vol. 24-12, July 15, 2024
Rule 911.
(1) A
					 bill for the following ancillary services shall include a copy of a written
					 prescription by a licensed practitioner. Documentation of a prescription drug
					 or medical supply in the clinical record shall constitute the prescription for
					 services dispensed in a practitioner's office or in a health care organization.
(a) Prescription medications.
(b) Medical supplies and equipment, except
					 when dispensed by a facility or health care organization.
(c) Hearing aids, shoes, and wigs.
(d) Home health services.
(e) Orthoses and prostheses.
(f) Physical and occupational
					 therapy.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 9 - BILLING › Subpart A - PRACTITIONER BILLING › Section R. 418.10912 - Billing for prescription medications

Current through Vol. 24-12, July 15, 2024
Rule 912.
(1)
					 Prescription drugs may be dispensed to an injured worker by either an
					 outpatient pharmacy or a healthcare organization. These rules apply to the
					 pharmacy dispensing the prescription drugs to an injured worker only after the
					 pharmacy has either written or oral confirmation from the carrier that the
					 prescriptions or supplies are covered by workers' compensation
					 insurance.
(2) When a generic drug
					 exists, the generic drug must be dispensed. When a generic drug does not exist,
					 the brand name drug may be dispensed. A physician may only write a prescription
					 for "DAW," or dispense as written, when the generic drug has been utilized and
					 found to be ineffective or has caused adverse effects for the injured worker. A
					 copy of the medical record documenting the medical necessity for the brand name
					 drug must be submitted to the carrier.
(3) A bill or receipt for a prescription drug
					 from an outpatient pharmacy, practitioner, or healthcare organization must be
					 submitted to the carrier and include the name, address, and Social Security
					 number of the injured worker. An outpatient pharmacy shall bill the service
					 using the National Council for Prescription Drug Program (NCPDP) Workers"
					 Compensation/Property & Casualty Universal Claim Form or an invoice and
					 include either the pharmacy"s NPI or NCPDP number, and the NDC of the
					 prescription drug.
(4) A healthcare
					 organization or physician office dispensing the prescription drug shall bill
					 the service on the CMS 1500 claim form. Procedure code 99070 must be used to
					 code the service and the national drug code must be used to describe the
					 drug.
(5) If an injured worker has
					 paid for a prescription drug for a covered work illness, then the worker may
					 send a receipt showing payment, along with the drug information, to the carrier
					 for reimbursement.
(6) An
					 outpatient pharmacy or healthcare organization shall include all of the
					 following information when submitting a bill for a prescription drug to the
					 carrier:
(a) The brand or chemical name of
					 the drug dispensed.
(b) The NDC
					 number from Red Book or Medi-Span, as adopted by reference in
					 R 418.10107.
(c) The dosage, strength, and quantity
					 dispensed.
(d) The date the drug
					 was dispensed.
(e) The physician
					 prescribing the drug.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 9 - BILLING › Subpart A - PRACTITIONER BILLING › Section R. 418.10913 - Billing for durable medical equipment and supplies

Current through Vol. 24-12, July 15, 2024
Rule 913.
(1)
					 DME and supplies must be billed using the appropriate descriptor from the HCPCS
					 Level II codebook, as referenced in
					 R 418.10107, for the service. If
					 the equipment or supply is billed using an unlisted or not otherwise specified
					 code and the charge exceeds $35.00, then the acquisition cost must be included
					 with the bill.
(2) Initial claims
					 for rental or purchased DME must be filed with a prescription for medical
					 necessity, including the expected time span the equipment is
					 required.
(3) Durable medical
					 equipment may be billed as a rental or a purchase. If possible, the provider
					 and carrier shall agree before dispensing the item as to whether it should be a
					 rental or a purchased item. With the exception of oxygen equipment, rented DME
					 is considered purchased equipment once the monthly rental allowance exceeds the
					 purchase price or payment of 12 months rental, whichever comes first.
(4) If the worker's medical condition changes
					 or does not improve as expected, then the rental may be discontinued in favor
					 of purchase.
(5) If death occurs,
					 rental fees for equipment terminates at the end of the month and additional
					 rental payments must not be made.
(6) The return of rented equipment is the
					 dual responsibility of the worker and the DME supplier. The carrier is not
					 responsible and shall not be required to reimburse for additional rental
					 periods solely because of a delay in equipment returns.
(7) Oxygen equipment must be considered a
					 rental as long as the equipment is medically necessary. The equipment rental
					 allowance includes reimbursement for the oxygen contents.
(8) A bill for an expendable medical supply
					 must include the brand name and the quantity dispensed.
(9) A bill for a miscellaneous supply, for
					 example, a wig, shoes, or shoe modification, must be submitted on an invoice if
					 the supplier is not listed as a healthcare professional.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 9 - BILLING › Subpart A - PRACTITIONER BILLING › Section R. 418.10915 - Billing for anesthesia services

Current through Vol. 24-12, July 15, 2024
Rule 915.
(1)
					 Anesthesia services shall consist of 2 components. The 2 components are base
					 units and time units. Each anesthesia procedure code is assigned a value for
					 reporting the base units. The base units for an anesthesia procedure shall be
					 as specified in the publication entitled "Medicare RBRVS: The Physicians'
					 Guide" as adopted by reference in
					 R 418.10107. The anesthesia codes,
					 base units, and instructions for billing the anesthesia service shall be
					 provided separate from these rules on the agencys website,
www.michigan.gov/wca
.
(2) When billing for both the
					 anesthesiologist and a certified registered nurse anesthetist or a certified
					 anesthesiologist assistant, the anesthesia procedure code shall be listed on 2
					 lines of the CMS 1500 with the appropriate modifier on each line.
(3) One of the following modifiers shall be
					 added to the anesthesia procedure code to determine the appropriate payment for
					 the time units:
(a) Modifier -AA indicates
					 the anesthesia service is administered by the anesthesiologist.
(b) Modifier -QK indicates the
					 anesthesiologist has provided medical direction for not more than 4 qualified
					 individuals being a certified registered nurse anesthetist
(CRNA)
,
					 certified anesthesiologist assistant (AA), or resident. The CRNA, AA, or
					 resident may be employed by a hospital, the anesthesiologist, or may be
					 self-employed.
(c) Modifier AD
					 indicates an anesthesiologist has provided medical supervision for more than 4
					 qualified individuals being either a certified registered nurse anesthetist,
					 certified anesthesiologist assistant, or anesthesiology resident.
(d) Modifier -QX indicates the certified
					 registered nurse anesthetist or certified anesthesiologist assistant has
					 administered the procedure under the medical direction of the
					 anesthesiologist.
(e) Modifier -QZ
					 indicates the certified registered nurse anesthetist has administered the
					 complete anesthesia service without medical direction of an
					 anesthesiologist.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 9 - BILLING › Subpart A - PRACTITIONER BILLING › Section R. 418.10920 - Billing for supplementary radiology supplies

Current through Vol. 24-12, July 15, 2024
Rule 920.
(1) If
					 a description of a diagnostic radiology procedure includes the use of contrast
					 materials, then those materials shall not be billed separately as they are
					 included in the procedure.
(2) A
					 radiopharmaceutical diagnostic low osmolar contrast materials and paramagnetic
					 contrast materials shall only be billed when the CPT codebook instructions
					 indicate supplies shall be listed separately.
(3) If allowed separate reimbursement under
					 this rule, a provider shall include an invoice documenting the wholesale price
					 of the contrast material used and the provider shall be reimbursed the
					 wholesale price of the contrast material.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 9 - BILLING › Subpart A - PRACTITIONER BILLING › Section R. 418.10921 - Facility billing

Current through Vol. 24-12, July 15, 2024
Rule 921.
(1)
					 Except for a freestanding surgical outpatient facility, a licensed facility as
					 defined in these rules shall submit facility charges on a UB-04 claim form to
					 the carrier. A copy of the UB-04 form shall be published separate from these
					 rules in a manual provided on the agency's website at
www.michigan.gov/wca
. The Official
					 UB-04 Data Specifications Manual referenced in these rules contains
					 instructions for facility billing.
(2) A facility billing for a practitioner
					 service shall bill charges on the CMS 1500 claim form.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 9 - BILLING › Subpart A - PRACTITIONER BILLING › Section R. 418.10922 - Hospital billing instructions

Current through Vol. 24-12, July 15, 2024
Rule 922.
(1) A
					 hospital shall bill facility charges on the UB-04 national uniform billing
					 claim form and shall include revenue codes, ICD-10-CM and ICD-10-PCS coding,
					 HCPCS codes, and CPT&reg procedure codes to identify the surgical,
					 radiological, laboratory, medicine, and evaluation and management services.
					 This rule only requires that the following medical records be attached when
					 appropriate:
(a) Emergency room
					 report.
(b) The initial evaluation
					 and progress reports every 30 days whenever physical medicine, speech, and
					 hearing services are billed.
(c)
					 The anesthesia record when billing for a CRNA, certified anesthesiologist
					 assistant, or anesthesiologist.