California Worker’s Compensation

California Worker’s Compensation AAPC Chapter Meeting Presented by: Deb Kuehn, CPC, CRS April 16, 2009

2003Reforms: SB 228 & AB 227 • Outpatient Facility Fee Schedule--Created a new outpatient facility fee schedule based on 120% Medicare. Fee update 99201-99215 Feb 07 • Cap on Chiropractor and physical therapy- 24/claim. • Pharmaceutical Fee Schedule--100% of Medi-Cal. • Physicians Services Fee Schedule Cut--5% reduction but not below the Medicare fee schedule rate.

Overview of CA Worker’s Compensation • California law requires the provider to treat the patient at no cost to the patient • CA fees are set forth in the Official Medical Fee Schedule (OMFS) • OMFS dictates how much a provider can be paid for a particular service. • Most OMFS fees are set at Relative Value Unit (RVU) times the conversion factor.

Official Medical Fee Schedule • Current CA OMFS conversion factors are: • Evaluation and management - $12.50 • CPT Procedures and Medicine - $12.50 • Surgical Procedures - $153.00 • Example: • 99204 – New patient Evaluation and Management Visit is 12.9 RVU x $12.50 = $161.25 • 26600 – Closed treatment of metacarpal fracture, single, without manipulation is 1.1 RVU x $153.00 = $161.30

OMFS and Outdated CPT • Most OMFS services use the codes and descriptors of the 1997 edition of (CPT) nomenclature for reporting medical services and procedures. • The physical medicine subsection of the OMFS is based on the 1994 CPT. (Neither the 1994 or 1997 CPT are currently supported by the AMA.) • The use of outdated codes makes it difficult for providers and payers to understand and use the current OMFS.

Medical Necessity • CA OMFS requires all services provided to be medically necessary • Medical necessity is defined as a service: • Provided as remedial treatment for an on-the-job illness or injury, and • Appropriate to the patient’s diagnosis and clinical conditions in relation to any industrial injury; and • Performed in an appropriate setting; and • Consistent with published medical literature and practice Ground Rules generally accepted by the practitioner’s peer group.

Primary Treating Physician (PTP) • The “primary treating physician” is the physician who is primarily responsible for managing the care of an employee. • The provider must have examined the employee at least once for the purpose of rendering or prescribing treatment. • The provider has monitored the effect of the treatment thereafter.

Coding And Billing • OMFS uses CPT Evaluation and Management Codes • Supply bundling rules same as current CPT coding with some exceptions • OMFS will reimburse separately for: • Casting and strapping materials • Taping supplies for sprains • Iontophoresis electrodes • Reusable patient electrodes • DME Items • Application of a cold pack as a modality is not separately reimbursable but a dispensed cold pack is. ($9.22)

Durable Medical Equipment (DME) • OMFS reimburses DME items on the DMEPOS fee schedule up to 120% of fee schedule • DMEPOS fee schedule items are billed with the applicable HCPCS codes • Invoice is not required for DMEPOS paid items • DME items include: • Crutches • Canes • Splints • Braces • Moist Heat Packs

Durable Medical Equipment (DME) • DME items or supplies not on the DMEPOS fee schedule are paid By Report (BR) • Use CPT code 99070 for these items • DME items can be billed at acquisition cost (including tax and freight) plus 50% not to exceed a maximum amount of $25.00 • Non DME items can be billed at acquisition cost plus 20% up to a maximum amount of $15.00 • The carrier has the right to request a purchase invoice on non-DMEPOS paid supplies.

Phamaceuticals • Immunizations for codes 90725-90749 and 90710-90711 are reimbursable at the cost of the vaccine plus $15.00 for administration. • All other vaccine codes cannot be reimbursed for an administration fee in addition to the vaccine. • Oral Medications are reimbursed based on the Medi-Cal website fee by NDC number.

Sample Medication Fee

Pharmaceuticals • Pharmacy drugs not paid under Medi-Cal system are paid using CPT code 99070 at the lesser of: • Providers usual charge or • The fee established by the formulas for brand name and generic pharmaceuticals • This applies to all pharmaceuticals dispensed by a provider regardless of site of service. • All prescription medications allow for the $7.25 dispense fee per prescription. • Over the counter medications are not eligible for a dispense fee even though they may be prescribed by the provider.

Pharmacy Formulas • For Brand Name pharmaceuticals the formula is the average wholesale price (AWP) times 1.10 plus a $4.00 dispensing fee. • For generic pharmaceuticals the formula is the average wholesale price (AWP) times 1.40 plus a $7.50 dispensing fee. • When a generic costs more than a brand name the price will be the brand name equivalent calculated under the above formula.

Pharmaceuticals • CA Worker’s Compensation requires that the National Drug Code (NDC) number be on the CMS claim form for a drug to be paid • DWC requires providers to be current with NDC numbers and fees within 90 days of updates to the Medi-Cal fee schedule

Surgical Procedures • Surgical Procedures are paid by the unit value in OMFS times the conversion factor • Certain procedures are designated as By Reports (BR) with no unit values • Unlisted or BR services are paid based on the time and effort required for the procedure. • Documentation submitted should include: • Report of the procedure/service performed • Complexity of symptoms and final diagnosis • Pertinent physical findings • Diagnostic and therapeutic procedures • Concurrent problems and follow up care

Starred Procedures • OMFS still has the starred * procedure designation • Starred procedures at the time of an initial visit if the procedure is the primary service reported with CPT code 99025 • Starred procedures have no global days. • Under OMFS simple and small intermediate laceration repairs have no global days. • CPT 12002 a 3cm laceration of the scalp has no global days • All follow up care is coded and billed separately.

Medical Provider NetworksMPNs • MPN is created by the carrier as a base of providers by specialty • Many carriers have specific guidelines for providers they enroll • Providers must meet requirements for: • Proven documentation compliance • Geographic availability • Report writing compliance • Employer/Insurer Control • Treatment must meet medical guidelines • Employee’s first visit is to employer’s choice. • Employee may change physicians within the MPN.

Non-Reimbursed Reports • Some treatment reports required under OMFS are not separately reimbursable. They include: • Doctor’s First Reports of Occupational Illness or Injury (DFR) • Initial treatment report and plan • Treating Physician’s Report of Disability Status (DWC Form RU-90) • Report by Secondary Provider to the PTP

Doctor’s First Report of Occupational Injury or Illness • Submit within 5 working days following the initial examination • Submit this report using Form DLSR 5021 • Emergency and urgent care physicians are also required to submit a Form DSLR 5021 following the initial visit • Each new primary treating physician is required to submit a Form DLSR 5021 • following initial examination of the employee

Reimbursable Reports • Reimbursable Reports include: • Primary Treating Physician’s Progress Reports (PR2) • Final Treating Physician’s Reports of Disability Status (DWC RU-90) • Primary Treating Physician’s Final Discharge report • Primary Treating Physician’s Permanent and Stationary Report

PTP Reporting Responsibilities • The primary treating physician is responsible for submitting reports to the claims administrator as required by the California Code of Regulations, Title 8, §9785. • Sending only one copy of the required report to the claims administrator satisfies the reporting requirement. • Reports may be transmitted to the claims administrator by mail or FAX or by any other means satisfactory to the claims administrator, including electronic transmission.

PR2 Narrative Report • If a narrative report is used, it must: • be entitled “Primary Treating Physician’s Progress Report” in boldfaced type; • indicate clearly the reason the report is being submitted; • contain the same information using the same subject headings in the same order as Form PR-2; • And as in Form PR-2, contain the following declaration: “I declare under penalty of perjury that this report is true and correct to the best of my knowledge that I have not violated Labor Code §139.3”

Primary Treating Physician’s Progress Report (PR2) Submit report within 20 days when any one or more of the following occurs: • The employee’s condition undergoes a previously unexpected significant change; • There is any significant change in the treatment plan reported, including but not limited to: • an extension of duration or frequency of treatment • new need for hospitalization or surgery • new need for referral to or consultation by another physician • change in methods of treatment or in required physical medicine services, or • need for rental or purchase of durable medical equipment or orthotic devices;

PR2 (cont) • The employee’s condition permits return to modified or regular work; • The employee’s condition requires him or her to leave work, or requires changes in work restrictions or modifications; • The employee is released from care; • The primary treating physician concludes that the employee’s permanent disability precludes, or is likely to preclude the employee from engaging in the employee’s usual occupation or the occupation in which the employee was engaged at the time of the injury;

PR2 (cont) • Submit report within forty-five days from the last report if no event described above has occurred. • If examination has occurred, submit the report within 20 days of the examination. • Submit this report using Form PR-2 or in the form of a narrative report. • Reimbursement for the PR2 report is $11.69

Primary Treating Physician’s Permanent and Stationary Report • Submit report when the employee’s condition is determined to be permanent and stationary (P & S) • Submit report within 20 days from the date of examination • Report must include: • any findings concerning the existence and extent of permanent impairment limitations, and • any need for continuing and/or future medical care resulting form the injury. • Submit the report using Form PR-4

P & S Report • Billing for a P & S report is performed with: • Appropriate E/M level for the evaluation • CPT code 99080 for the report pages up to a maximum of 6 • CPT code 99354-99358 for prolonged services. • CPT code 99358 can be used for billing review of extensive medical records from other sources. • 99358 is billable in 15 minute increments. ($36.34 per 15 minutes) • Requires provider to document what was reviewed and how the information was used in the treatment plan.

Requests for appropriate additional information by the claims administrator • A claims administrator may request additional information necessary to administer the claim • Submit response to this request by using Form PR-2, or in a narrative report letter format. • A letter format response must also include the same declaration under penalty of perjury as found in Form PR-2

Consultation Reports • OMFS follows E/M Guidelines for Consultation report criteria • Confirmatory Consultation Codes are still applicable CPT 99271-99275 • Consultation codes may not be billed when care has been transferred by the PTP to another physician

OMFS Specific Modifiers • Modifier 18 – Used to identify a form which is not legally mandated or contains additional information requested by a claims administrator. • Modifier 19 – Reports a return E/M visit on same date of service. • Modifier 30 – Consultation service during Med-Legal evaluation • 86 – Used to indicate prior authorization received for services which exceed OMFS ground rules • .

OMFS Specific Modifiers (Cont) • Modifier 88 – Used to identify claims for a marriage, family and child counselor or licensed clinical social worker. • Modifier 93 – Interpreter required at time of examination • OMFS pays 10% premium above E/M fee schedule fee for use of interpreter • Documentation must indicate first and last name of interpreter • No requirement for who the interpreter can be.

Physical Therapy • Physical and Occupational Therapy is capped under OMFS at 24 visits • Regardless of provider type visits can only total 24 • PT evaluations are still 1997 codes with 5 levels for new and 4 for re-evaluation. • CPT codes 98770-98778 • PT services billable only once every 30 days without prior auth.

Physical Therapy (cont.) • No more than 4 physical medicine procedures/modalities reimbursed in one visit. • Multiple physical medicine and acupuncture services are reimbursed as follows: • Major (highest valued allowable procedure or modality); 100% of listed max allowable fee • Second (second highest value allowable procedure or modality) 75% of listed maximum allowable fee • Third (third highest valued allowable procedure or modality): 50% of listed maximum allowable fee • Fourth (fourth highest valued allowable procedure or modality): 25% of listed maximum allowable fee

Physical Therapy (cont) • Physical Medicine codes include routine follow up assessment for evaluation and management purposes. • When separate E/M service is provided on same day 2.4 units of value are deducted from the treatment codes ($14.76) • CPT codes 97700-97752 cannot be billed with an E/M code

OMFS allows a premium fee for after hours and holiday unscheduled visits. • After Hours is defined as any unscheduled visit between 6:00 PM and 7:00 AM Monday – Friday • This designation in OMFS is regardless of the normal operating hours of the clinic. • CPT code 99050 ($22.20) is billed in addition to the E/M service

After Hours and Holidays • Services provided on Sundays and Holidays are billed with CPT code 99054 ($25.12) • This service is billed in addition to the Evaluation and Management service. • CPT Code 99058 ($28.63) is used to report office services provided on an emergency basis. • This code can be used when a medical emergency presents during clinic hours and the provider interrupts care of another patient to treat the emergency.

Questions • Contact Information • Deb.Kuehn@USHWorks.com • 661-678-2438

California Worker’s Compensation