Louisiana Medical Bill Reviewer Training Program

1. Louisiana Medical Bill Reviewer Training Program Unit 1: Professional Services Introduction and General Guidelines

2. Hi! I’m one of the symbols of Louisiana. I’m here to guide you on a tour of our Workers’ Compensation fee schedule rules. Together, we’ll become familiar with the unique aspects of our guidelines. Overview Part I: General Information • History • Part II: Processing Guidelines • Separate Procedures • Unlisted Procedures • Locator Codes • Modifiers • Calculating Reimbursements

3. History The Louisiana Office of Workers’ Compensation Administration (OWCA) was created in 1983 in order to administer the Louisiana Workers’ Compensation Act. The Workers’ Compensation Board of Commissioners consist of 12 members, 9 are appointed by the Governor. State Capital Building Baton Rouge, LA

4. Louisiana Workers’ Compensation Act • The OWCA offers numerous services to the employees and employers of Louisiana, a few are . . . • Administrative, Finance and Compliance, Fraud, Hearings, Legal, Medical Services and Second Injury Fund. Which workers are covered? • Seasonal • Part-time • Employees of non-profit organizations • Employees of unincorporated businesses • A single employee of a small business

5. Louisiana Workers’ Compensation Act The Louisiana Workers’ Compensation Act provides for: Benefits are paid by: • Medical expenses • Wage-loss compensation benefits • Death benefits (for work-related deaths paid to dependent survivors) • Private insurance companies • Employers themselves, if self-insured • Group Self Insurance

6. Fee Schedules • The State of Louisiana uses three fee schedules to determine payment for services rendered to Workers’ Compensation patients. They are . . . • Hospital Fee Schedule – efft. 01/01/94 • Medical Fee Schedule – efft. 03/20/01 • Pharmacy Fee Schedule – efft. 03/20/01 Periodic updates are provided by the state to allow the schedules to remain current.

7. Louisiana Workers’ Compensation The Workers’ Compensation Program is a large melting pot of many different entities. Injured Workers Employers Service Providers Insurance Companies Labor Unions Attorneys Regulation Agencies

8. General Information and Instructions Now that you are familiar with the framework of Louisiana Workers’ Comp, let’s take a look at some general guidelines & instructions... • Part I: General Information • History • Part II: Processing Guidelines • Locator Codes • Calculating Reimbursements • Separate Procedures • Procedures Without Unit Value • Modifiers

9. Locator Codes • Louisiana uses one locator code in the BR4 system – 999 • The code is determined by zip code location and impacts both professional and facility bills. How do I find a Louisiana locator code? Let’s take a look…

10. Locator Codes Step 1: Access Bill Review 4 Reference Materials

11. Locator Codes Step 2: Choose State Reference Guides

12. Locator Codes Step 3: Choose Fee Schedule Location Table

13. Locator Codes Step 4: Find the provider’s zip code and the effective date of service on the table to locate the provider’s fee schedule locality.

14. Changing a Billed Procedure Code • There is a reluctance with most workers’ compensation departments and boards to allow payers to change billed codes. • This is seen as a possible way to manipulate payment without the provider’s permission. In Louisiana, altering codes is not allowed. Key the procedure as billed.

15. Balance Billing Balance Billing is prohibited by Louisiana • Louisiana’s guidelines read, “For covered services, if there is a difference between the provider’s billed amount and the Office of Workers’ Compensation maximum allowable reimbursement, the claimant, employer and carrier cannot, under any circumstances be billed for the difference.

16. Some listed procedures are carried out as an integral part of a total service, while other procedures are independent of additional services. Procedures that are integral parts of a total service DO NOT warrant separate identification or reimbursement. Separate Procedures • Separate Procedure: a procedure independent of, and not immediately related to, other services performed, for which reimbursement is ALLOWED. Let’s take a look…

17. For Example: Separate Procedures CPT 95851, which codes for a Range of Motion procedure, is an essential part of a follow up visit for a shoulder injury. Therefore, it WOULD NOT warrant separate reimbursement. However, if this procedure were the only service performed, it would be considered a separate procedure and should be ALLOWED.

18. Unlisted Procedures Every effort should be made to identify the service performed with a specific code rather than an unlisted procedure. If the necessity of the services has been verified, and the service authorized, additional information may be requested about the procedure, or an online search may be performed. The unlisted code billed may represent a slightly different version of an established code which would still be appropriate. Procedure codes that do not have a listed value will be recommended for payment at the UCR percentage allowance.

19. Unlisted Procedures • Every effort should be made to identify the service performed with a specific code rather than an unlisted procedure code. Hmm, which code should I use? • As you know, providers often misuse the unlisted code when a more appropriate code is available.

20. Sales Tax • Sales Taxes and other state mandated taxes are required to be reimbursed in addition to other procedures, supplies or medical services.

21. Dental Services • The CDT (Current Dental Terminology) procedure codes (00110-09999) are the primary codes to be used for dental billing. • All dental procedure codes use type of service ‘I’. Although, the system will suspend for the user to verify the correct type of service.

22. Physical Medicine • Physical and Occupational therapy services require medical necessity documentation for every 30-day period of treatment. • Services rendered in excess of 45 days from the initial treatment evaluation, require documentation of medical necessity.

23. Out-of-State Bills • Medical services rendered outside of the • State of Louisiana are reimbursed, based • on the provider’s domicile. • Bill Review recommends payment for • these services according to the rules set • by the state in which treatment was • provided. • When there are no guidelines, UCR • allowances for the geographic area are • applicable.

24. Timeliness of Payment • Providers are required to be paid for • services rendered within 30 days of the • receipt of a statement for medical services • provided, unless the claim has been • contested or denied. • Any provider who renders services must • submit the statement for services to the • payor within 30 days of the day treatment is • initiated

25. Modifiers indicate that a procedure was altered by additional circumstances, but was not changed from its standard definition. Modifiers Modifiers will be covered in the context of billed codes. Modifiers may indicate circumstances such as: • Only part of the whole procedure was performed. • A bilateral procedure was performed.

26. Calculating Reimbursements • Reimbursement rates are tied to values published in the official Louisiana fee schedule.

27. Calculating Reimbursements • It is important to know that the Bill Review system calculates and applies these reimbursements for you. But, as you can see, knowing how to calculate reimbursements may help you identify errors during bill review or troubleshoot problems when reviewing challenging bills.

28. Description of modifiers, separate procedures and unlisted procedures. Defined Locator Codes How reimbursements are calculated. Summary Louisiana Workers’ Comp Overview.