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2010 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

 

Drugs

 

Emergency / Medical

 

General

1. Part II of the General Rules contained in the 2010 Fee Schedule establishes the most current version of the AMA’s Current Procedural Terminology, the ASA’s Relative Value Guide, and CMS’s HCPCS Level II codes, in effect at the time service is rendered, as the authoritative coding standard for workers’ compensation medical bills. However, what is the payment rule for current codes being billed which are not in the Fee Schedule and/or do not have a specific fee set forth in the Schedule?

 

While the Commission requires billing to be based on the most current applicable codes in effect at the time service is rendered, we also realize that the most current codes are not always going to be listed in the Schedule with a specific fee. The Commission, at least annually, tries to identify all of the new, changed and deleted codes which have been adopted since the publication of the latest Fee Schedule, and make this list available as a free update on our web site. This list will include specific fees in most instances for codes not currently in the Schedule, or not in the most recent update. An updated list, along with specific fees, has not yet been completed and published since the Schedule was last updated July 1, 2010. Therefore, until this update occurs, payment for current codes/services which are not included in the Schedule is handled by our default payment rule set forth in Part I.A. of the Billing and Reimbursement Rules section of the Schedule, and which provides as follows:

    “Maximum Reimbursement Allowance (MRA). Unless the payer and provider have a separate fee contract which provides for a different level of reimbursement, the maximum reimbursement allowance for health care services shall be the lesser of (a) the provider’s total billed charge, or (b) the maximum specific fee established by the Fee Schedule. Items or services or procedures which do not have a maximum specific fee established by this Fee Schedule shall be reimbursed at the usual and customary fee as defined in this Fee Schedule [use the Ingenix MDR database of Relative and Actual Charge Data, MS State Version, at the 40th percentile, to determine the UC fee], and in such cases, the maximum reimbursement allowance shall be the lesser of (1) the provider’s total billed charge, or (2) the usual and customary fee as defined by this Fee Schedule.

    If this Fee Schedule does not establish a maximum specific fee for a particular service or procedure, and a usual and customary rate cannot be determined because the Ingenix MDR Payment System database does not contain a fee for same, then the maximum reimbursement allowance shall be equal to the national Medicare allowance plus thirty percent (30%). In the absence of an established Medicare value, and assuming none of the above provisions apply, the maximum reimbursement allowance shall be the provider’s total billed charge.”


As a point of clarification regarding payments at the usual and customary rate, please note in the current Fee Schedule, Introduction Part IV, “usual and customary rate” is defined as the “reimbursement allowance equal to the amount displayed by the Ingenix MDR Payment System (Mississippi State Version) for the procedure at the 40th percentile. The Ingenix MDR Payment System is a national database of Relative and Actual Charge Data (RACD) which includes charge information for the State of Mississippi.” This particular Database is being gradually phased out, and will be succeeded by FairHealth RV Benchmark Database effective 06-01-11. Both databases are updated monthly and the allowable may change throughout the year, and from and after June 1, 2011, either or both of the databases may be used to calculate the usual and customary rate, for so long as both databases are being fully maintained and updated monthly.

2. While treating a patient for a work-related orthopaedic injury, I requested the patient undergo an MRI, and I specifically requested the MRI be conducted at a certain facility. The payer declined to approve the MRI at the facility I requested, and instead advised they would only approve the MRI being done with one of their preferred network providers. Can the payer unilaterally redirect patient care for diagnostic tests such as an MRI?

 

3. While treating a patient for a work related injury, I recommended the patient undergo an EMG/NCS. I requested to administer the test myself at my clinic, but the payer refused to authorize this, and instead unilaterally redirected the patient to another EMG/NCS provider because I was not in their preferred network of providers for this service. I am otherwise qualified to administer this test and prefer to do my own EMG/NCS testing. Is this permissible under the Fee Schedule?

 

The payer, in both of these instances, clearly violated the Rules contained in the Mississippi Workers' Compensation Medical Fee Schedule. In particular, General Rules, Part X on page 11-12 of the 2010 Mississippi Workers Compensation Medical Fee Schedule states:

X. SELECTION OF PROVIDERS. The selection of appropriate providers for diagnostic testing or analysis, including but not limited to CAT scans, MRI, x-ray, and laboratory, for physical or occupational therapy, including work hardening, functional capacity evaluations, back schools, chronic pain programs, or massage therapy shall be at the direction of the treating or prescribing physician. In the absence of specific direction from the treating or prescribing physician, the selection shall be made by the payer, in consultation with the treating or prescribing physician. Physical or occupational therapy, including work hardening, functional capacity evaluations, back schools, chronic pain programs, or massage therapy shall be provided upon referral from a physician. In the absence of specific direction from the treating or prescribing physician, the selection of a provider for these services shall be made by the payer in consultation with the treating or prescribing physician.

Referral for an electromyogram and/or a nerve conduction study shall be at the discretion and direction of the physician in charge of care, and neither the payer nor the payer's agent may unilaterally or arbitrarily redirect the patient to another provider for these tests. The payer or the payer's agent may, however, discuss with the physician in charge of care appropriate providers for the conduct of these tests in an effort to reach an agreement with the physician in charge as to who will conduct an electromyogram and/or nerve conduction study in any given case.

This same rule is repeated in the Physical Medicine Rules, Part XI(c), wherein in states:

XI. ELECTROMYOGRAM (EMG) AND NERVE CONDUCTION STUDY (NCS)

C. Referral for an electromyogram and/or a nerve conduction study shall be at the discretion and direction of the physician in charge of care, and neither the payer nor the payer's agent may unilaterally or arbitrarily redirect the patient to another provider for these tests. The payer or the payer's agent may, however, discuss with the physician in charge of care appropriate providers for the conduct of these tests in an effort to reach an agreement with the physician in charge as to who will conduct an electromyogram and/or nerve conduction study in any given case.

 

4. What criteria should be used for editing bundling or unbundling issues?

 

Both CPT Assistant and NCCI edits can be used. In some instances, these two sources conflict. When there is a conflict the NCCI rule will take precedence.

 
Inpatient

 

Modifiers & Code Exceptions

1. What is the percentage reimbursement that should be associated with the use of an assistant surgeon applying modifier 82? A specific reimbursement percentage is set forth in the Fee Schedule with similar modifier explanations, such as modifier 80, 81, and AS; what percentage should be paid to the assistant surgeon under modifier 82?

Both modifiers 80 and 82 describe essentially the same services of an assistant surgeon. Therefore, the services of an assistant surgeon billing under either modifier 80 or modifier 82 should be reimbursed at twenty percent (20%) of the maximum reimbursement allowance.

 

Medicine

 

Outpatient

1. Effective January 1, 2011, CMS as well as the AMA adopted two new CPT codes, 22551 and 22552. Code 22551 replaces codes 63075 and 22554, when used together. Code 22552 replaces codes 63076 and 22585, when used together. What is the correct facility reimbursement rate for these two new neurosurgical codes?

 

 The facility reimbursement rate (APC Amount) for CPT 22551 is $4,488.88. The facility reimbursement rate (APC Amount) for 22552 is, likewise, $4,488.88. Since the Commission has not yet elected to specifically price these two codes in accordance with the relative weighting assigned by CMS, we have elected instead to assign an APC Amount which is based on the current APC Amount for CPT Codes 63075 and 63076 (the two higher valued codes which have been replaced with 22551 and 22552). This APC Amount shall apply until further notice.

 

2. Are implants still billed and paid separately by invoice for all outpatient billings? It looks like reimbursement for implants is already included in the APC Amounts listed in the Schedule. If we pay the APC Amount and the provider submits an invoice for implant reimbursements, how do we reimburse for this?

 

  Unfortunately, we have discovered that our vendor, despite instructions to the contrary, did not exclude the implant amount before publishing the final APC Amounts. Therefore, in order to avoid paying twice for the same implant, you should first reduce the applicable APC Amount to take out the implant cost. The amount of this reduction is based on the current year's device offset percentage for each APC, as established by CMS. This means you will use the CMS device offset table in effect at the time service was rendered. Go back to the main page for the 2010 Fee Schedule and look under the “General Information” heading. There you will find the device offset percentage tables for CY 2010, CY 2011 and CY 2012. For other years, check the CMS website. These tables may not always be found in the same place, but currently they can be found at https://www.cms.gov/hospitaloutpatientpps/apf/itemdetail.asp?itemid=CMS1253695

 

Pain Management

1. My request for an epidural injection was denied because the physician reviewer said the patient did not "meet ODG guidelines" for an epidural injection.  Does the Mississippi Workers' Compensation Fee schedule use the ODG guidelines as a means of determining appropriateness of treatment?

 

NO.  In fact, the 2010 Fee Schedule update specifically precludes the use of ODG (or any other extraneous guidelines) as the sole means of determining appropriateness of care.  The criteria for the use of epidural injections, and many other pain management procedures, are included, and have been updated, in the Pain Management section of the 2010 fee schedule.

 

2. I performed an epidural steroid injection on a patient, but when I requested a second injection, it was denied because the patient didn't have an EMG.  Are EMGs required for repeat epidural injections?  How do I get this pre-certified?

 

If an epidural injection has been approved, repeat epidural injections for the same pain in the same patient do not require prior approval, as long as you have documented some benefit after the first procedure.  Your records must clearly reflect that you feel there was at least a partial response to the prior injection, but insurance carrier authorization for repeat injections is not otherwise required.  If you fail to document in the records any response to the injection, your claim may be denied. 

 

3. So I don't need prior approval for epidural injections?

 

You DO need prior approval to initiate a trial of epidural injections.  However, once an epidural injection has been improved, you do NOT need approval for repeat procedures (up to 3 total injections) if you document a positive response to the previous injection.  This documentation can be in the form of a lower pain score, improvement in exam findings, or even a notation in the chart that the patient is "better", but this positive response information must be in the medical records.  These records should be submitted to the insurance company if requested, but do not have to be available on the day of the procedure.  This is intended to avoid having a patient who has traveled (often) for long distances, and has brought a driver who has taken off work, from having to reschedule for a procedure that does not need prior authorization.  The MWCC recognizes that records often have to be dictated and transcribed, and that this process may take days, so while documentation is required, it does not have to be available at the time of the procedure.  Again, this is intended to prevent unnecessary loss of time (and often money) to both the patient and the insurance carrier.

 

4. My first epidural injection was approved, but when I did a second one because the patient was better, the insurance carrier refused to pay because I didn't get prior-approval.  What should I do?

 

Mostly likely, your insurance carrier is not aware of the 2010 MWCC Medical Fee Schedule changes regarding epidural injections.  Effective July 1, 2010, you must have documented partial relief with the first injection, though not necessarily prior to the repeat injection as discussed in an earlier FAQ.  Assuming you did so, you should initially inform the payer of the new Fee Schedule, which became effective July 1, 2010.  You could also mention the section you are reading now on the MWCC web site.  Once you have made the carrier aware of the changes, you probably won't have further difficulties.  If there continues to be a problem, you should contact the MWCC at 601-987-4200, and request to speak with Medical Cost Containment.  Or you can contact the Medical Cost Containment Director by email to cmills@mwcc.state.ms.us.

 

5. Guidelines pertaining to sacroiliac joint injections, which are billed using CPT Code 27096, are contained in the Pain Management section of the 2010 Fee Schedule at Part V.J and Part V.S., pages 83 and 86. However, this particular CPT Code does not appear in the list of CPT Codes and their related fees which are part of the Pain Management section. What is the proper reimbursement for this Code when used in the Pain Management setting?

 

CPT Code 27096 was inadvertently left out of the Pain Management section, and is instead only listed in the Surgery section. The reimbursement amount for the physician billing this Code in the Pain Management setting is $435.87. The APC Amount for this Code, when used in the Pain Manage setting should be $482.98.

 

6. When billing for an injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid, using CPT Code 27096, some payers are rejecting payment based on our failure to bill using either HCPCS Codes G0259 or G0260. Is CPT Code 27096 proper for billing this procedure?

 

HCPCS codes G0259 and G0260 were originally created to replace CPT code 27096 in order to facilitate appropriate reporting and payment under HOPPS (Hospital Outpatient Prospective Payment System). However, 27096 is still an appropriate procedure code for billing this service, and in the section of our Fee Schedule titled “Durable Medical Equipment (DME), Orthotics, Prosthetics and Other HCPCS Codes,” at page 448, Part II.G.2., we state, in explaining the use of “G” codes that: “Procedures and professional services identified by G codes may have a corresponding CPT code. When both a G code and CPT code describe the same procedure, the CPT code is required for reporting purposes.” Hence, the required billing code for this procedure is CPT 27096, and a claim is not to be rejected based on failure of the provider to bill using the corresponding HCPCS “G” codes. The “G” codes should be used only for “procedures and professional services that do not currently have a valid CPT code.” MS Workers' Compensation Medical Fee Schedule, Durable Medical Equipment (DME), Orthotics, Prosthetics and Other HCPCS Codes, Part II.G.3 (2010).

 

7. What is the proper way to reimburse for CPT Code 77003?

 

A professional fee payable to the physician is allowed for CPT Code 77003, regardless of the site of service, for any services which in which fluoroscopic guidance is not considered inclusive of the underlying procedure. The physician fee allowance is $121.92. This procedure code and professional fee amount is listed in the Radiology section of the Schedule. The current CPT manual clearly describes the list of underlying procedures for which 77003 is considered inclusive, and hence no separate payment is allowed. There is no separate facility fee payment (or APC Amount) for procedure 77003, effective for services provided on or after July 1, 2010. From August 1, 2007 to June 30, 2010, a facility fee of $100.00 was allowed for this procedure when performed in the pain management setting, payable once per date of service, but this minimum facility fee was not carried forward in the 2010 update to the Schedule.

 

8. I recommended that a patient receive a trial of epidural injections for their back pain that radiates into the leg, but it was denied, because the patient didn't have any motor or sensory loss, or EMGs that demonstrated nerve damage. Are these conditions precedent for an injured worker to receive an epidural injection in Mississippi?

 

NO. EMGs are NOT required, and the patient may well have a normal neurological exam (motor/sensory). In fact, the outcome from a steroid injection is often likely to be better when is there isn't nerve damage. The steroids in an epidural injection are used to treat inflammation, not nerve damage. Steroids are anti-inflammatory medications, not pain killers, and the pain relief is due to reduction of inflammation, not healing of the nerve damage. Nerve regeneration, if it occurs at all, is a physiological process that requires time. Even surgery does not "undo" damage that has already happened, though it can speed recovery by preventing further damage. Steroid injections are NOT typically used when there is evidence of progressive nerve damage. Page 79 of the Pain Management section of the Fee Schedule (I.C.4.) requires appropriate documentation of radiating/radicular pain, but there is no requirement for nerve damage as demonstrated either by exam or electro-physiological findings (EMG). In Mississippi, consistent with the recommendations of multiple national and international pain intervention societies, we require evidence of radiating or radicular pain (radiculopathy or radiculitis) in order to proceed with epidural steroid injections. Spinal stenosis with symptoms or radiating gluteal or extremity pain, is also an indication for epidural steroids, though there is no requirement that nerve damaged be present.

Pathology and Lab

1. How are lab fees paid in the out-patient facility setting?

 

This will vary depending on the services performed. Charges for out-patient surgery are paid based on the APC system. Some CPT codes, including many in the laboratory/pathology section of the Schedule, have an APC amount of 0.00, which is indicated by a blank space in the APC Amount column of the Schedule. These services are not reimbursed since there is no APC Amount. However, any procedure/CPT code which is not listed in the Schedule at all will not have an APC Amount, obviously, and is therefore, paid at the usual and customary rate, as that phrase is elsewhere defined in the Schedule.

When lab services are provided as part of an Emergency Room visit, the lab charges are reimbursed from the "Amount" column. In cases, where there are PC/TC (professional component and technical component) amounts specified, payment is at the TC maximum value. When lab services are provided without an out-patient surgery service, or Emergency Room service, the lab charges are also paid from the "Amount" column. If PC/TC components apply, the TC component is paid.

 
Physical Medicine

1. While treating a patient for a work-related orthopaedic injury, I requested the patient undergo an MRI, and I specifically requested the MRI be conducted at a certain facility. The payer declined to approve the MRI at the facility I requested, and instead advised they would only approve the MRI being done with one of their preferred network providers. Can the payer unilaterally redirect patient care for diagnostic tests such as an MRI?

 

2. While treating a patient for a work related injury, I recommended the patient undergo an EMG/NCS. I requested to administer the test myself at my clinic, but the payer refused to authorize this, and instead unilaterally redirected the patient to another EMG/NCS provider because I was not in their preferred network of providers for this service. I am otherwise qualified to administer this test and prefer to do my own EMG/NCS testing. Is this permissible under the Fee Schedule?

 

The payer, in both of these instances, clearly violated the Rules contained in the Mississippi Workers' Compensation Medical Fee Schedule. In particular, General Rules, Part X on page 11-12 of the 2010 Mississippi Workers Compensation Medical Fee Schedule states:

X. SELECTION OF PROVIDERS. The selection of appropriate providers for diagnostic testing or analysis, including but not limited to CAT scans, MRI, x-ray, and laboratory, for physical or occupational therapy, including work hardening, functional capacity evaluations, back schools, chronic pain programs, or massage therapy shall be at the direction of the treating or prescribing physician. In the absence of specific direction from the treating or prescribing physician, the selection shall be made by the payer, in consultation with the treating or prescribing physician. Physical or occupational therapy, including work hardening, functional capacity evaluations, back schools, chronic pain programs, or massage therapy shall be provided upon referral from a physician. In the absence of specific direction from the treating or prescribing physician, the selection of a provider for these services shall be made by the payer in consultation with the treating or prescribing physician.

Referral for an electromyogram and/or a nerve conduction study shall be at the discretion and direction of the physician in charge of care, and neither the payer nor the payer's agent may unilaterally or arbitrarily redirect the patient to another provider for these tests. The payer or the payer's agent may, however, discuss with the physician in charge of care appropriate providers for the conduct of these tests in an effort to reach an agreement with the physician in charge as to who will conduct an electromyogram and/or nerve conduction study in any given case.

This same rule is repeated in the Physical Medicine Rules, Part XI(c), wherein in states:

XI. ELECTROMYOGRAM (EMG) AND NERVE CONDUCTION STUDY (NCS)

C. Referral for an electromyogram and/or a nerve conduction study shall be at the discretion and direction of the physician in charge of care, and neither the payer nor the payer's agent may unilaterally or arbitrarily redirect the patient to another provider for these tests. The payer or the payer's agent may, however, discuss with the physician in charge of care appropriate providers for the conduct of these tests in an effort to reach an agreement with the physician in charge as to who will conduct an electromyogram and/or nerve conduction study in any given case.

 

Radiology

 

Surgery

1. Effective January 1, 2011, CMS as well as the AMA adopted two new CPT codes, 22551 and 22552. Code 22551 replaces codes 63075 and 22554, when used together. Code 22552 replaces codes 63076 and 22585, when used together. What is the correct reimbursement rate for these two new neurosurgical codes?

 

As noted above in the General Rules section, all new codes introduced since July 1, 2010, as well as any existing codes, which do not have a specific fee set forth in the Schedule, are subject to our default payment rule which states that reimbursement shall be the lesser of total billed charges, or the usual and customary fee as defined in the Schedule. In the case of these two new codes in particular, the usual and customary fee, as determined by using the Ingenix MDR database (MS State Version) at the 40th percentile, for CPT 22551 is currently is $7353.54, and the usual and customary fee for CPT 22552 is currently $2106.91, for the Jackson area (geo-zip 392). Therefore, in the geo-zip 392 area at least, the proper reimbursement for CPT 22551 and 22552 will be the lesser of billed charges, or these usual and customary amounts, until such time as the Commission issues an update to the Schedule which establishes specific fees for these and other new or missing codes.

 

1.a. Effective January 1, 2011, CMS as well as the AMA adopted two new CPT codes, 22551 and 22552. Code 22551 replaces codes 63075 and 22554, when used together. Code 22552 replaces codes 63076 and 22585, when used together. What is the correct facility reimbursement rate for these two new neurosurgical codes?

 

 The facility reimbursement rate (APC Amount) for CPT 22551 is $4,488.88. The facility reimbursement rate (APC Amount) for 22552 is, likewise, $4,488.88. Since the Commission has not yet elected to specifically price these two codes in accordance with the relative weighting assigned by CMS, we have elected instead to assign an APC Amount which is based on the current APC Amount for CPT Codes 63075 and 63076 (the two higher valued codes which have been replaced with 22551 and 22552). This APC Amount shall apply until further notice.

 

2. What is the percentage reimbursement that should be associated with the use of an assistant surgeon applying modifier 82? A specific reimbursement percentage is set forth in the Fee Schedule with similar modifier explanations, such as modifier 80, 81, and AS; what percentage should be paid to the assistant surgeon under modifier 82?

 

Both modifiers 80 and 82 describe essentially the same services of an assistant surgeon. Therefore, the services of an assistant surgeon billing under either modifier 80 or modifier 82 should be reimbursed at twenty percent (20%) of the maximum reimbursement allowance.


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