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2002 Medical Fee Schedule Frequently Asked Questions

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The Mississippi Workers Compensation Medical Fee Schedule cannot address all issues or questions which may arise in the course of the medical management of a workers compensation claim.  However, both providers and payers should use common sense, make a good faith effort,  and be reasonable in their handling of claims.

Anesthesia

On anesthesia, it is my understanding that the units are allowed in 15 minute increments and that any portion of the 15 minutes is paid as an additional unit. Is that correct or can it be paid by the minute?

It is paid as an additional unit. We do not pro rate portions of units.

I would like to clarify Anesthesia Reimbursement rule number 5 on page 51. Regarding the statement "when an anesthesiologist directs a CRNA, the total reimbursement amount for the anesthesia will not exceed the amount allowed for that procedure." How should this scenario be reimbursed?

We did not specify how it is to be reimbursed. This would be between the MD and CRNA. All we say is total reimbursement can not exceed 100% of the allowable fee schedule amount.

Drugs

Are we legally bound to use Redbook, or can we use the Medispan program?

Red Book as specified in guidelines of the Fee Schedule is what you are to use. Anything not listed is to be reduced to usual and customary.

Emergency / Medical

 

General

If a service is provided to a claimant out of state, whose rule for reimbursement of records applies? (i.e. If seen in Alabama do we have to pay copy costs for Alabama or do the Mississippi rules apply?)

Our rules and regulations always apply if this is a Mississippi jurisdiction.

What is the jurisdiction of the Mississippi Workers Compensation Fee Schedule?
The Fee Schedule is applicable for services provided within the state of Mississippi. It applies to injured workers, whether Mississippi claims or not. If a Mississippi claimant is treated in a neighboring state, then the Fee Schedule of that state is applicable.
 
If a procedure is not listed in the Fee Schedule, what is the reimbursement rate?
A procedure code that is not listed in the Fee Schedule should be reimbursed at the usual and customary rate.
 
Are medical records required for reimbursement of medical charges?
Yes, employers/payers need medical records for review of diagnosis and applicability to the workers compensation claim.
 
Is there a dental fee schedule?
No, there is no dental fee schedule in Mississippi. The reimbursement for dental services should be at the usual and customary rate.
 
Can the reimbursement for medical services be reduced lower than the Fee Schedule amount?
Yes, if an employer/payer has a contractual agreement with a provider designed to reduce the cost of workers compensation health services, the contractual agreement shall be exempt from the fee schedule.
 
Can medical payments be made on controverted/litigated claims?
Yes, reimbursement for medical charges may be made on controverted claims. However, the employer/payer may suspend payments of indemnity and/or medical pending a decision by an administrative judge.
 
What is the penalty for untimely filing of medical charges or untimely payment of medical charges?
It is ten percent (10%) per 30-day period.
 
HCFA-1500 form and documentation must be filed within 20 days for a newly diagnosed work-related injury or injury; and within 30 days for subsequent billings. Otherwise, the bill may be reduced by 10% for each 30-day period for late billing.
 
Likewise, payment of properly submitted, documented, bills should be made with 30 days of receipt. If no payment is made within 60 days, then a payer may be subject to penalties not to exceed 10% for each 30-day period after 60 days.
 
Is the employee or employer responsible for the balance of a paid charge?
No, if the payment has been made properly according to the medical fee schedule, then fees in excess of the maximum reimbursement allowable rate must not be billed to the employee or employer.

If authorization is given for medical treatment, can payment be denied when bill received?
No. When authorization is given, services are provided in good faith, therefore, payment must be rendered. Reimbursement determinations shall be based on medical necessity of services to either establish a diagnosis or treat an injury/illness. Thus reimbursement shall not be dependent on the outcome of medically necessary diagnostic services or treatment.
 
Are Explanation of Benefits forms required with every payment of medical charges?
No, but the Explanation of Benefits form is required whenever the reimbursement amount is less than the charged amount, and it must be provided with the reimbursement check.
 
If the carrier disputes a bill, is payment required? What action is required?
The carrier is required to pay the undisputed portion of the bill within 30 days of receipt. And for the disputed portion, the carrier shall notify the provider within 30 day of the receipt of the bill of the reasons for disputing the bill or portion thereof, and shall notify the provider of its right to provide additional information and to request reconsideration of the carrier's action. The carrier must specify the reasons of dispute.
 
How can the medical provider request reconsideration of reimbursement?
The provider must make a written request within 30 days from receipt of the Explanation of Benefits form. Allowances may be made by payer for the period of time in submission of reconsideration requests. The payer must respond within 30 days of receipt to the request for reconsideration. The payer must review and re-evaluate the original bill and respond accordingly. If the medical provider is still dissatisfied, then a request for dispute resolution should be filed with the MWCC Medical Cost Containment Department.
 
May a Mississippi injured worker receive medical treatment out of state?
Yes, however, prior authorization must be obtained from the payer for referral to out-of-state providers. Reimbursement for out-of-state services shall be based on one of the following: the workers' compensation fee schedule for the state in which services are rendered or the usual and customary fee for the geographical area in which the services are rendered.
 
When can the payer receive the report of Maximum Medical Improvement?
The physician should submit a report with the date of MMI to the payer or self-insured employer within 14 days of the date of MMI date even though the employee may require further medical care. MMI is reached when the maximal benefit from medical treatment is as far restored as the permanent character of his injuries will permit and/or the current limits of medical science will permit.
 
What is the reimbursement rate for Medical Depositions and Affidavits?
Reimbursement for a deposition is limited to $350 for the first hour and $85 per quarter hour thereafter.
The Physician's Medical Record Custodian is allowed to sign the affidavit in lieu of physician's signature. Such charge for execution of the affidavit is limited to a maximum reimbursement of $25. Reimbursement for copies of medical records is outlined in the fee schedule and applies to copies of medical records which are attached to affidavits.
 
What is the reimbursement rate for Medical Records?
There is no charge to the payer for the initial medical reports attached to medical charge form.
Additional medical reports will be reimbursed as follows:
1-5 pages - $15.00
6+ pages - $ 0.50 per page in addition to the first 5 pages.
 
Hospitals and other inpatient facilities must submit required documentation with the UB-92.
a) Admission, history, and physical
b) Discharge summary
c) Operative reports
d) Pathology reports
e) Consultations and other dictated reports
f) Emergency Room Records
 
Any additional reports or records requested by the payer will be reimbursed as follows:
1-5 pages - $15.00/per admission
6+ pages - $ 0.50/per page/per admission in addition to the first 5 pages.
 
There is a maximum allowed fee of $50 for a particular inpatient medical record. This is per admission.
 
What medical treatment may be denied?
Treatment of conditions unrelated to the injuries sustained in an industrial accident may be denied as unauthorized if the treatment is directed toward the non-industrial condition or if the treatment is not deemed necessary for the patient's rehabilitation from the industrial injury.
 
Are experimental or investigational procedures covered by the fee schedule?
No, the service must be widely accepted by the practicing peer group, based on scientific criteria, and determined to be reasonably safe. It must not be of an experimental, investigational, or research in nature except in those instance in which prior approval of the payer has been obtained.
 
What are medically necessary services?
Medically necessary services are either those required for the remedial treatment or diagnosis of an on-the-job injury, a work-related illness, a pre-existing condition affected by the injury or illness, or a complication resulting from the injury or illness and for such period as the nature of the injury or process of recovery may require.
 
Is there a separate charge for a report of release from a physician?
No, a plan of care should be included in the medical record and should address, as applicable, the following:
a) Degree of restoration anticipated
b) Measurable goals
c) Specific therapies to be used
d) Frequency and duration of treatments to be provided
e) Anticipated return to work date
f) Projected impairment
 
What is the pharmacy reimbursement rate?
Average Wholesale Price for the purpose of this fee schedule means AWP base on the updated Drug Topics Red Book.
Brand name Medications - AWP plus $5.00 dispensing fee
Generic Medications - AWP plus 10% plus $5.00 dispensing fee
Over-the counter medications - usual and customary rates.
 
What is the authorization response time from payers?
Two days, the payer must respond within two (2) days to a request of prior authorization for non-emergency services.
 
Which medical treatments require prior authorization by payer?
1) Non-emergency elective inpatient hospitalization
2) Non-emergency elective inpatient surgery
3) Non-emergency elective outpatient surgery
4) Physical medicine treatments after 15 visits or 30 days, whichever comes first
5) Rental or purchase of supplies or equipment over the amount of $50 per item
6) Rental or purchase of TENs
7) Home health services
8) Pain clinic/therapy programs
9) External Spinal stimulators
10) Pain control programs
11) Work hardening programs, back schools, functional capacity testing, ISO kinetic testing
12) Referral for orthotics or prosthetics
13) Referral for acupuncture
14) Referral for biofeedback
15) Referral to psychological testing/counseling
16) Referral to substance abuse program
17) Referral to weight reduction program
18) Referral to any non-emergency medical service outside the state of Mississippi
 
Which medical treatments require prior certification or mandatory utilization review?
1) All admissions to inpatient facilities of any type
2) All surgical procedures, inpatient and outpatient
3) Repeat MRI (Magnetic Resonance Imaging) more than 1 per injury
4) Repeat CAT (Computerized Axial Tomography) more than 1 per injury
5) Work Hardening Programs, Pain Management Programs, Back Schools, Massage Therapy, Acupuncture, Biofeedback
6) External Spinal Stimulators
7) FCE and Isokinetic testing
8) Physical Medicine treatments
9) Home Health
 
What is the appeal process for denial of medical necessity by utilization review?
First level clinical review of admissions, procedures, and services may be conducted by registered nurses and other appropriate licensed or certified health professionals.
Second level clinical review is conducted by appropriate clinical peers.
Third level clinical review is conducted by appropriate clinic peers who were not involved in second level review.
Commission Peer Review may then be requested through the Commission of an objective physician in that specialty field.
 
What is the reimbursement rates for hospitals?
Inpatient rates are based on a daily per diem depending on the type of stay, surgical, medical, etc. When specific criteria are met, an additional Stop Loss amount may be paid, which is 80% of the additional allowable amount.
 
Outpatient rates are listed in 9 groupings in the Ambulatory Surgery Centers Appendix. This is in addition to appropriate separately reimbursed items.
 
When is next Fee Schedule update?
This year 2002 approximately August, effective date November 1, 2002, the Updated Mississippi Workers Compensation Medical Fee Schedule will be available. Preliminary copy available at the Commission for viewing.
 
Where can the 2002 Fee Schedule be obtained?
 
Click here to go directly to the Medicode website.
 
Mississippi Workers' Compensation Fee Schedule
c/o Ingenix/Medicode, Inc.
P O Box 27116
Salt Lake City, UT 84127-0116
877-464-3649
 
Who do I contact at the Commission for questions related to the Fee Schedule?
 
Mississippi Workers' Compensation Commission
Medical Cost Containment Department
P O Box 5300
Jackson, MS 39296-5300
601-987-4280
shofmister at mwcc.state.ms.us (replace the 'at' with @ and remove the spaces).

Inpatient

 

Medicine

 

Outpatient

When an outpatient visit is billed and it is not an ASC bill and not an ER bill, if there are charges for EKG, can they be paid at fee schedule plus 10%?

Yes.

When the patient goes to the hospital as outpatient for a myelogram and they charge a fee for revenue code 360 or 361 and bill for the injection for the myelogram, that should be denied and the other charges paid as separate outpatient x-ray and lab. Is this correct?

Yes, deny 360 or 361. Pay S & I to hospital, and pay lab as separate outpatient. The technical portion of the procedure pays for use of the facility.  Also, pay for the injection.

I need to know if we should be paying a 23-hour surgery differently from an outpatient surgery. I have been paying them as the same but have been asked about why I do not pay observation charges in addition to the surgery. Which is correct?

It is an outpatient surgery as long as it is under 24 hours.  The definitions of observation are listed in the fee schedule.  It states that we do not pay observation on standing orders. If you are referring to the calls from Methodist Rehab Center, this is nothing but outpatient surgery with standing orders for observation following outpatient surgery. I have told them to forward the disputes to me and I would be glad to look at them. They have just realized they are only getting $600 and $700 for outpatient surgeries. Outpatient is for a period not to exceed 23 hours.

Pain Management

The CPT's for pain management listed in the hospital fee schedule should be removed from the ASC list and the facility charges should be paid at the rates given in the Pain Management Section, in all cases. Is this correct?

Yes.

Pathology and Lab

In the lab section: for those codes that do not have an amount for the professional component, is it correct that we do not pay the facility and the physician both but only have to pay the facility the total component?

Yes.

Physical Medicine

I have a question about code 97545.  On page 380 of the fee schedule under #19(b), it reads that this code is "a one-time charge." Does this statement mean that the reimbursement of this code should be once per date of service or once per injury?

It means once per injury.

Radiology

 

Surgery

We have a patient who had surgery in Birmingham, but a Mississippi physician is taking over her care post-op. The local physician billed for the surgical procedures with a modifier 55. I understand that the fee schedule says that is the appropriate way to bill his services, but I do not know how to pay him. Does he get a percentage of the allowance?

He billed correctly; however, we do not have a policy on how to pay. The M.D.'s should agree on the percentage. However, it is usually 70% for the surgery and 30% for post-op. care.


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