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Department of Labor : Division of Industrial Affairs >> Office of Workers' Compensation

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FREQUENTLY ASKED QUESTIONS

spacerLast Update Monday October 19 2009

QUESTIONS:

REFERENCES:
Title 19 Del.C. §2322B
Procedures and requirements for promulgation of health care payment system.

19 DE Admin. Code 1341 - Section 4.0
Fee Schedule Introduction and Guidelines

  1. Why do some codes have fees set for them and others don't? What does POC85 mean?
  2. What is a geozip?
  3. What is a modifier?
  4. Where can I find the "Correct Coding Policy Manual?"
  5. Where can I find the "Payment Guide to Global Days?"
  6. How and when are the fees adjusted each year? Where can I find the indicators used to adjust the fees - Consumer Price Index--Urban, U.S. City Average, All Items, as published by the United States Bureau of Labor Statistics (the "fee schedule") ,as well as the Consumer Price Index-Urban, U.S. City Average, Medical (ASTCs and Hospitals)?
  7. How are HCPCS codes reimbursed?
  8. Did the OWC adopt the new MS-DRGs?
  9. Does the fee schedule apply to medical treatments before May 23, 2008?
  10. Are emergency services exempt from the HCPS and fee schedule?
  11. Does the Delaware fee schedule address missed appointments?
  12. Should we pay medical bills according to our contract or the fee schedule?
  13. How do I reimburse for an out-of-state treatment?
  14. How do you reimburse for the pharmaceutical drugs and/or drugs listed on the OWC Preferred Drug List?
  15. What is the dispensing fee for pharmaceutical drugs?

REFERENCES:
Title 19 Del.C. §2322F
Billing and payment for health care services.

19 DE Admin. Code 1341 - Section 4.0
Fee Schedule Introduction and Guidelines

  1. Is balance billing allowed?
  2. How do I pay bills where there are professional and technical components (PC/TC)?
  3. Should a medical provider send bills to the employer or the payer?
  4. What can I do if the payer won't pay me correctly?
  5. Is the interest on medical bills owed if the claim is disputed for valid reasons but later determined to be compensable?
  6. Must bills be submitted on certain forms?
  7. Can you tell me if I am calculating a bill correctly?
  8. How should the payer handle a bill with incorrect codes? Can the payer alter the codes on a bill? Does the fee schedule allow for down-coding?
  9. When an ambulance travels from one geozip to another, which one should count for billing?
  10. How do we reimburse assistant surgeons?
  11. How do we handle bilateral/multilateral procedures?
  12. How should providers bill for exposure surgeons as indicated in 7.6 DE Admin code 1342 of the low back practice guidelines?

REFERENCES:
Title 19 Del.C. §2322F
Billing and payment for health care services.

19 DE Admin. Code 1341 - Section 5.0
Utilization Review

  1. How would a utilization review (UR) provider become eligible to perform utilization review for the Delaware Workers' Compensation Health Care Payment System?
  2. How does the new law on utilization review affect the process at the OWC?
  3. What date should be used to begin counting the number of occurrences when determining a Utilization Review (UR)?
  4. What is the deadline for processing a Utilization Review (UR) request?

REFERENCES:
Title 19 Del. C. §2322D
Certification of health care providers.

19 DE Admin. Code 1341 - Section 3.0
Health Care Provider Certification

  1. Who has to become certified to treat injured workers?
  2. Does the DOL issue certification numbers to certified providers?

REFERENCES:
Title 19 Del. C. §2322E
Development of consistent forms for health care providers.

19 DE Admin. Code 1341 - Section 6.0
Forms

  1. What CPT code should providers use for the physician's report (provider form) and what is the fee? When should physicians fill out the form?
  2. When should I fill out the provider or employer forms?

MISCELLANNEOUS

  1. How does HIPAA affect workers' compensation?
  2. Are any injured workers exempt from coverage under the Delaware Workers' Compensation Act?
  3. Where can I find a list of the 7/6/09 changes to Title 19 Del.C. §2322?

ANSWERS:

REFERENCES:
Title 19 Del.C. §2322B
Procedures and requirements for promulgation of health care payment system.

19 DE Admin. Code 1341 - Section 4.0
Fee Schedule Introduction and Guidelines

  1. Why do some codes have fees set for them and others don't? What does POC85 mean?


    2. Excluding those exceptions mandated in the Delaware Code plus CPT Code 99080 (used for the physicians form), the fee schedule was populated with an actual fee dollar amount based on a certain threshold of occurrences for the CPT codes. When that CPT code occurred less than the threshold frequency, the scheduled fee was set at 85% (85POC) of the actual charge.

    Pursuant to the Administrative Regulations for the Introduction & Fee Schedule Guidelines:

    4.4.1 The maximum allowable payment for health care treatment and procedures shall be the lesser of the health care provider's actual charges or ninety percent (90%) of the 75th percentile of actual charges within the geozip where the service or treatment is rendered, utilizing information contained in employers' and insurance carriers' national databases. If an employer or insurance carrier contracts with a provider for the purpose of providing services under the Act, the rate negotiated in such contract shall prevail.

    4.4.2 Whenever the health care payment system does not set a specific fee for a procedure, treatment or service in the schedule, the amount of reimbursement shall be eighty-five percent (85%) of actual charge ("POC 85"), which actual charge will be fixed as of 11/1/08 and subsequent to such date will be subject to verification, audit and/or review by the Department of Insurance.

    Reasonable costs of such review or audit shall be reimbursed to the Department of Insurance by the health care provider whose billing is audited. From the effective date of this regulation through and including 10/31/08, the "POC 85" charges, if contested, will be subject to review pursuant to a Hearing to be conducted before the Industrial Accident Board.

    4.4.3 The payment system will be adjusted yearly from the date the Health Care Advisory Panel recommended adoption of the fee schedule, November 14, 2007, based on percentage changes to the Consumer Price Index--Urban, U.S. City Average, All Items, as published by the United States Bureau of Labor Statistics.

  2. What is a geozip?


    3. Purusant to Title 19 Del. C. §2322B,
    "...the payment system will set fees at ninety percent (90%) of the 75th percentile of actual charges within the geozip where the service or treatment is rendered, utilizing information contained in employers' and insurance carriers' national databases. For purposes of the Act, "geozip" means an area defined by reference to United States ZIP Codes; Delaware shall consist of one "197 geozip" (comprised of all areas within the State where the address has a ZIP Code beginning with the three digits 197 or 198), and one "199 geozip" (comprised of all areas within the State where the address has a ZIP Code beginning with the three digits 199). If a geozip does not have the necessary number of charges and fees to calculate a valid percentile for a specific procedure, treatment or service, the Health Care Advisory Panel created pursuant to 19 Del.C. §2322(A), in its discretion may combine data from Delaware's two geozips for a specific procedure, treatment, or service. In the event that the Health Care Advisory Panel determines that there is insufficient data to calculate a valid percentile for a procedure, treatment or service, or that data from a commercial vendor is not sufficiently reliable to implement a payment system for professional services for a specific procedure, treatment or service, then the Health Care Advisory Panel may recommend an alternative method for a payment system for professional charges.

  3. What is a modifier?


    4. Modifiers augment CPT codes to more accurately describe the circumstances of services provided. When applicable, the circumstances should be identified by a modifier code: a two-digit number placed after the usual procedure code. If more than one modifier is needed, place modifier 99 after the procedure code to indicate that two or more modifiers will follow. Some modifier descriptions in this fee schedule have been changed from the CPT language.

  4. Where can I find the "Correct Coding Policy Manual?"


    5. The OWC adopted the National Correct Coding Initiative as the review standard for bundling edits. You may get information on the different types of service and code ranges at the link below: http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage

    Service Type Code Range
    Category III Codes 0001T - 9999T
    Anesthesia Services 00100 - 00999
    Anesthesia Services 01000 - 09999
    Surgery: Integumentary System 10000 - 19999
    Surgery: Musculoskeletal System 20000 - 29999
    Surgery: Respiratory, Cardiovascular, Hemic and
    Lymphatic Systems    		 30000 - 39999
    Surgery: Digestive System 40000 - 49999
    Surgery: Urinary, Male Genital, Female Genital,
    Maternity Care and Delivery Systems    		 50000 - 59999
    Surgery: Endocrine, Nervous, Eye and Ocular
    Adnexa, Auditory Systems    		 60000 - 69999
    Radiology Services 70000 - 79999
    Pathology and Laboratory Services 80000 - 89999
    Medicine Evaluation and Management Services 90000 - 99999
    Supplemental Services A0000 - V9999

  5. Where can I find the "Payment Guide to Global Days?"


    6. The Health Care Advisory Panel is currently working on this topic.

  6. How and when are the fees adjusted each year? Where can I find the indicators used to adjust the fees - Consumer Price Index--Urban, U.S. City Average, All Items, as published by the United States Bureau of Labor Statistics (the "fee schedule") ,as well as the Consumer Price Index-Urban, U.S. City Average, Medical (ASTCs and Hospitals)?


    7. Pursuant to Title 19 Del. C. §2322B(14), "One year after the effective date of the regulation and each year thereafter, the DOL shall make an automatic adjustment to the maximum payment for a procedure, treatment, or service in January of that year."

    Health Care Treatment and Procedures
    Pursuant to Title 19 Del. C. §2322B(3), "The payment system will be adjusted yearly based on percentage changes to the CPI-Urban, U.S. City Average, All Items.

    Ambulatory Service Treatment Centers
    Pursuant to Title 19 Del. C. §2322B(9)(b), "...adjusted annually by the DOL in accordance with the Consumer Price Index-Urban, U.S. City Average for Medical Care."

    Hospital Fees
    Pursuant to Title 19 Del. C. §2322B(8)(b) "...in accordance with the Consumer Price Index-Urban, U.S. City Average for Medical Care.
    You can find CPI information at the Bureau of Labor Statistics webpage: http://data.bls.gov/cgi-bin/surveymost?cu

    For the "fee schedule" you will need to check the first box that reads, "U.S. All items, 1982-84=100 - CUUR0000SA0."

    For Ambulatory Treatment Centers and Hospital fees, you will need to check the box that reads, "U.S. Medical Care, 1982-84=100 - CUUR0000SAM."

    The most recent update to the fee schedule includes the 2006-2007 change in the Consumer price index. You may find the percentage at the link below
    http://www.bls.gov/cpi/cpid07av.pdfpdf icon

    The percentage of change for the November 14, 2008, (1 year after the implementation date) update is +2.8% for "All items" and +4.4% (the "fee schedule") for "Medical Care" (ASTCs and Hospitals). The November 14, 2009, update will include the 2007-2008 change in the Consumer Price Index.

    The percentage of change for the November 14, 2007, (prior to the implementation date) update is +3.2% for "All items" (the "fee schedule"- already included at implementation date) and +4.0% for "Medical Care" (ASTCs and Hospitals). You may find the source information at the following link: http://www.bls.gov/cpi/cpid06av.pdfpdf icon

  7. How are HCPCS codes reimbursed?


    8. Users can find HCPCS reimbursement amounts in the fee schedule.

  8. Did the OWC adopt the new MS-DRGs?


    9. No. In the interest of facilitating transactions, we do encourage providers to use DRGs

  9. Does the fee schedule apply to medical treatments before May 23, 2008?


    10. No. The schedule only applies to treatments covered under the Act and provided on or after May 23, 2008. The date of injury is not relevant.

  10. Are emergency services exempt from the HCPS and fee schedule?


    11. Yes.

    Pursuant to Title 19 Del.C. §2322B(8)(c), "Services provided an emergency department of a hospital, or any other facility subject to the federal Emergency Medical Treatment and Active Labor Act, 42 U.S.C. § 1395dd, and any emergency medical services provided in a pre-hospital setting by ambulance attendants and/or paramedics, shall be exempt from the health care payment system and shall not be subject to the requirement that a health care provider be certified pursuant to § 2322D of this title, requirements for preauthorization of services, or the health care practice guidelines adopted pursuant to § 2322C of this title. Upon admission to a hospital and discharge from an emergency department, hospital charges shall be subject to paragraph (8)a. of this section."

    Although emergency services are exempt from the HCPS, you will still find "emergency" codes listed in the fee schedule data for two reasons:
    1. The data is a compilation of Delaware health care fees that reached a specific threshold of occurrences. Any items in the raw data that occurred over the specified threshold were included in the published fee schedule.
    2. Non-emergency facilities also use those codes when they render that type of treatment. Non-emergency facilities that provide those types of treatment services will need to use those codes.

  11. Does the Delaware fee schedule address missed appointments?


    12. No. The fee schedule only applies to services actually rendered in the treatment of an injured worker.

  12. Should we pay medical bills according to our contract or the fee schedule?


    13. Pursuant to Title 19 Del.C. §2322B(4), "If an employer or insurance carrier contracts with a provider for the purpose of providing services under this chapter, the rate negotiated in any such contract shall prevail."

  13. How do I reimburse for an out-of-state treatment?


    14. Pursuant to Title 19 Del.C. § 2322B(6),

    "(6) The health care payment system shall include provisions for health care treatment and procedures performed outside of the State of Delaware. If any procedure, treatment or service is rendered outside the State of Delaware, the amount of reimbursement shall be the greater of:
    1. The amount set forth in a workers' compensation health care payment system or fee schedule adopted by the state in which the procedure, treatment or service is rendered, if such a schedule has been adopted; or
    2. The amount that would be authorized by the payment system adopted pursuant to this chapter if the service or treatment were performed in the geozip where the injury occurred or where the employee was principally assigned. Charges for a procedure, treatment or service outside the State of Delaware shall be subject to the instructions, guidelines, and payment guides and policies in the health care payment system."

  14. How do you reimburse for the pharmaceutical drugs and/or drugs listed on the OWC Preferred Drug List?


    15. Pursuant to the Administrative Regulations for the Introduction & Fee Schedule Guidelines:

    "4.13 Pharmacy

    4.13.1 Reimbursement for pharmacy services, prescription drugs and other pharmaceuticals is 100% of the Average Wholesale Price (AWP) as of the date of service, or the actual charge, whichever is less. Verification that such billing is performed in compliance with the above and 19 Del.C. §2322B is subject to review or audit by the Department of Insurance. Reasonable costs of such review or audit for purposes of the above shall be reimbursed to the Department of Insurance by the provided whose billing is audited.

    4.13.2 A prescription drug formulary has been adopted and recommended by the Health Care Advisory Panel which designates preferred prescription drugs and encourages the use of generic drugs over name brand drugs."

    We are unable to publish the AWP reimbursement rates on this website. We suggest obtaining the AWP info from your insurance carriers or providers. The Medi-Span Master Drug Data Base (MDDB) or Drug Topics Red Book databases are also available for purchase through the following web sites:

    Redbook
    http://www.micromedex.com/products/redbook/

    Medispan
    http://www.medispan.com/marketing/ContentPage.aspx?contentId=9645d75e-f0b8-4db0-bca3-fb0339f0030a

  15. What is the dispensing fee for pharmaceutical drugs?


    16. The Delaware Workers' Compensation Health Care Payment System (HCPS) does not include a dispensing fee in the fee schedule at this time.

    REFERENCES:
    Title 19 Del.C. §2322F
    Billing and payment for health care services.

    19 DE Admin. Code 1341 - Section 4.0
    Fee Schedule Introduction and Guidelines

  16. Is balance billing allowed?


    17. Pursuant to Title 19 Del. C. §2322F(l), a provider shall not hold an employee liable for costs related to non-disputed services for a compensable injury and shall not bill or attempt to recover from the employee the difference between the provider's charge and the amount paid by the employer or insurance carrier on a compensable injury.

  17. How do I pay bills where there are professional and technical components (PC/TC)?


    18. Fees for total, professional, and/or technical reimbursement components may appear in the Professional Services fee schedule in the areas of surgery, radiology, pathology and laboratory, and medicine.

    When you receive a bill from a healthcare provider with no modifier, you can assume that the charge is for the total component, and pay the fee schedule amount for the "total component." If POC85 appears, pay 85% of the charged amount.

    When you receive a bill with the modifier "PC" or "26," the charge is for the professional component and is paid at the amount listed for the "professional component." If POC85 appears, pay 85% of the charged amount.

    When you receive a bill with the modifier "TC," this indicates the charge is for the technical component of the service and is paid at the amount listed for the "technical component." If POC85 appears, pay 85% of the charged amount.

    When combined, the TC/PC splits should equal the fee schedule (actual number or 85POC, whichever is appropriate) for the total component.

  18. Should a medical provider send bills to the employer or the payer?


    19. Send bills to the employer (if not insured) or insurance carrier.

    Pursuant to Title 19 Del.C. §2322F(a), "charges for medical evaluation, treatment and therapy, including all drugs, supplies, tests and associated chargeable items and events, shall be submitted to the employer or insurance carrier along with a bill or invoice for such charges, accompanied by records or notes, concerning the treatment or services submitted for payment, documenting the employee's condition and the appropriateness of the evaluation, treatment or therapy, with reference to the health care practice guidelines adopted pursuant to §2322C of this title, or documenting the pre-authorization of such evaluation, treatment or therapy."

  19. What can I do if the payer will not pay me correctly?


    20. A certified health care provider may file a petition to determine additional compensation due (DACD) with the Industrial Accident Board if they do not receive correct payment. Except for sole proprietors, providers will need to file their petition through an attorney. Sole proprietors may file a petition with or without an attorney.

    The Delaware Code and Administrative Regulations that govern this process are listed below.

    Title 19 Del. C. §2322F(a) - "(a) Charges for medical evaluation, treatment and therapy, including all drugs, supplies, tests and associated chargeable items and events, shall be submitted to the employer or insurance carrier along with a bill or invoice for such charges, accompanied by records or notes, concerning the treatment or services submitted for payment, documenting the employee's condition and the appropriateness of the evaluation, treatment or therapy, with reference to the health care practice guidelines adopted pursuant to §2322C of this title, or documenting the preauthorization of such evaluation, treatment or therapy. The initial copy of the supporting notes or records shall be produced without separate or additional charge to the employer, insurance carrier or employee."

    Administrative Regulations for the Introduction & Fee Schedule Guidelines:

    "4.15.9 An employer or insurance carrier shall be required to pay a health care invoice within thirty (30) days of receipt of the invoice as long as the claim contains substantially all the required data elements necessary to adjudicate the invoice, unless the invoice is contested in good faith. If the contested invoice pertains to an acknowledged compensable claim and the denial is based upon compliance with the health care payment system and/or health care practice guidelines, it shall be referred to utilization review. Unpaid invoices shall incur interest at a rate of one percent (1%) per month payable to the provider. A provider shall not hold an employee liable for costs related to non-disputed services for a compensable injury and shall not bill or attempt to recover from the employee the difference between the provider's charge and the amount paid by the employer or insurance carrier on a compensable injury.

    4.15.10 If, following a hearing, the Industrial Accident Board determines that an employer, an insurance carrier, or a health care provider failed in its responsibilities under 19 Del.C. §2322B, §2322C, §2322D, §2322E or §2322F, it shall assess a fine of not less than $1,000.00 nor more than $5,000.00 for violations of said sections, such fines shall be payable to the Workers' Compensation Fund."

  20. Is the interest on medical bills owed if the claim is disputed for valid reasons but later determined to be compensable?


    21. Pursuant to the Administrative Regulations for the Introduction & Fee Schedule Guidelines:

    4.15.8 In the event that a portion of a health care invoice is contested, the uncontested portion shall be paid without prejudice with the right to contest the remainder. The time limits set forth above and in §2322F shall apply to payment of all uncontested portions of health care payments.

    4.15.9 An employer or insurance carrier shall be required to pay a health care invoice within thirty (30) days of receipt of the invoice as long as the claim contains substantially all the required data elements necessary to adjudicate the invoice, unless the invoice is contested in good faith. If the contested invoice pertains to an acknowledged compensable claim and the denial is based upon compliance with the health care payment system and/or health care practice guidelines, it shall be referred to utilization review. Unpaid invoices shall incur interest at a rate of one percent (1%) per month payable to the provider. A provider shall not hold an employee liable for costs related to non-disputed services for a compensable injury and shall not bill or attempt to recover from the employee the difference between the provider's charge and the amount paid by the employer or insurance carrier on a compensable injury.

  21. Must bills be submitted on certain forms?


    22. The fee schedule guidelines (for instance 19 DE Admin. Code 1341, Sections 4.18.1 and 4.22.2) require payers to use the latest CMS-1500 and UB-04 forms.

  22. Can you tell me if I am calculating a bill correctly?


    23. No. We can provide general answers, as listed on this web page, but we do not have the resources to address individual calculations.

  23. How should the payer handle a bill with incorrect codes? Can the payer alter the codes on a bill? Does the fee schedule allow for down-coding?


    24. The payer should contact the provider and try to resolve such issues. If the parties cannot resolve the issue a petition may be filed with the state.

  24. When an ambulance travels from one geozip to another, which one should count for billing?


    25. The most common and universally accepted practice is to use the geozip of the place where the patient was picked up.

  25. How do we reimburse assistant surgeons?


    26. Pursuant to the Administrative Regulations for the Introduction and Fee Schedule Guidelines:

    "4.21.1.11 Surgical Assistant

    4.21.1.11.1 Physician surgical assistant - For the purpose of reimbursement, a physician who assists at surgery is reimbursed as a surgical assistant. Assistant surgeons should use modifier 80 and are allowed twenty percent (20%) of the maximum reimbursement allowance (MRA) for the procedure(s).

    4.21.1.11.2 Registered Nurse Surgical Assistant or Physician Assistant
    • A physician assistant (PA), or registered nurses (NP) who have completed an approved first assistant training course, may be allowed a fee when assisting a surgeon in the operating room (O.R.).
    • The maximum reimbursement allowance for the physician assistant or the registered nurse first assistant (RNFA) is twenty percent (20%) of the surgeon's fee for the procedure(s) performed.
    • Under no circumstances will a fee be allowed for an assistant surgeon and a physician assistant or RNFA at the same surgical encounter.
    • Registered nurses on staff in the O.R. of a hospital, clinic, or outpatient surgery center do not qualify for reimbursement as an RNFA."

  26. How do we handle bilateral/multilateral procedures?


    27. The Administrative Regulations for the Introduction and Fee Schedule guidelines contain explanations for over 30 different modifiers, including the modifiers for bilateral and multilateral procedures. Only those pertinent to this question are pasted below.

    Pursuant to the Administrative Regulations for the Introduction and Fee Schedule Guidelines:

    "4.18.3.9 Modifiers

    Modifiers augment CPT codes to more accurately describe the circumstances of services provided. When applicable, the circumstances should be identified by a modifier code: a two-digit number placed after the usual procedure code. If more than one modifier is needed, place modifier 99 after the procedure code to indicate that two or more modifiers will follow. Some modifier descriptions in this fee schedule have been changed from the CPT language.

    50 Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding modifier 50 to the appropriate five-digit code.

    51 Multiple Procedures: When multiple procedures, other than Evaluation and Management Services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). Note: This modifier should not be appended to designated "add-on" codes or modifier 51 exempt codes (See CPT Appendix D.)"

    Additionally, the Administrative Regulations for the Introduction and Fee schedule guidelines quoted below give billing instructions:

    "4.23 Multiple Procedures
    4.23.1 Multiple Procedure Reimbursement Rules
    Multiple procedures performed during the same operative session at the same operative site are reimbursed as follows:
    • One hundred percent (100%) of the allowable fee for the primary procedure
    • One hundred percent (100%) of the allowable fee for the second and subsequent procedures
    4.23.2 Bilateral Procedure Reimbursement Rule
    Physicians and staff are sometimes confused by the definition of bilateral. Bilateral procedures are identical procedures (i.e., use the same CPT code) performed on the same anatomic site but on opposite sides of the body.
    4.23.3 Multiple Procedure Billing Rules
    • The primary procedure, which is defined as the procedure with the highest RVU, must be billed with the applicable CPT code.
    • The second or lesser or additional procedure(s) may be billed by adding modifier 51 to the codes unless the procedure(s) is exempt from modifier 51or qualifies as an addon code."

    Title 19 Del. C.§2322B(10) also specifies the coding sources and states the following:

    (10) Professional service fees developed in the health care payment system shall be determined in accordance with the following provisions:
    1. The payment system for professional services shall conform to the Current Procedural Terminology ("CPT"), American Medical Association, 515 North State Street, Chicago, Illinois, 60610, 2006, no later dates or editions.
    2. Services covered by the payment system shall include evaluation and management, surgery, physician, medicine, radiology, pathology and laboratory, chiropractic, physical therapy, and other services covered under the CPT.
    3. The health care payment system shall require that services be reported with the Healthcare Common Procedural Coding System Level II ("HCPCS Level II") or CPT codes that most comprehensively describe the services performed. Proprietary bundling edits more restrictive than the National Correct Coding Policy Manual in Comprehensive Code Sequence for Part B Medicare Carriers, Version 12.0, U.S. Department of Health and Human Services, Centers for Medicare and Medicare Services, 7500 Security Boulevard, Baltimore, Maryland, 21244, 2006, no later dates or editions, shall be prohibited. Bundling edits is the process of reporting codes so that they most comprehensively describe the services performed.
    4. An allied health care professional, such as a certified registered nurse anesthetist ("CRNA"), physician assistant ("PA"), or nurse practitioner ("NP"), shall be reimbursed at the same rate as other health care professionals when the allied health care professional is performing, coding and billing for the same services as other health care professionals if a physician health care provider is physically present when the service or treatment is rendered, and shall be reimbursed at 80% of the primary health care provider's rate if a physician health care provider is not physically present when the service or treatment is rendered.
    5. Charges of an independently operated diagnostic testing facility shall be subject to the professional services and HCPCS Level II health care payment system where applicable. An independent diagnostic testing facility is an entity independent of a hospital or physician's office, whether a fixed location, a mobile entity, or an individual nonphysician practitioner, in which diagnostic tests are performed by licensed or certified non-physician personnel under appropriate physician supervision.

  27. How should providers bill for exposure surgeons as indicated in 7.6 DE Admin Code 1342 of the low back practice guidelines?


    28. In procedures where a surgeon provides exposure and another surgeon performs the primary surgical procedure, each surgeon may bill the CPT code or codes representing their respective part of the operation. Thus, co-surgery rules do not apply. For example, retroperitoneal exposure may be billed as CPT 49010 exploration of the retroperitoneum of the lumbar spine, or CPT 32100 major thoracotomy for the thoracic spine.

    REFERENCES:
    Title 19 Del.C. §2322F
    Billing and payment for health care services.

    19 DE Admin. Code 1341 - Section 5.0
    Utilization Review

  28. How would a utilization review (UR) provider become eligible to perform utilization review for the Delaware Workers' Compensation Health Care Payment System?


    29. The Department of Labor issues a Request for Proposals (RFP) every 2 years and goes through the State of Delaware contracting process to award contracts to those URAC accredited organizations who will perform utilization review (UR) for the Workers' Compensation Health Care Payment System (HCPS). Interested parties may send an e-mail to hcpaymentquestions@state.de.us if they would like to receive notice during the next contracting cycle. In the e-mail, explain that you would like to go on the mailing list to receive future RFP notices and include complete contact information (name, mailing address, e-mail address and phone number).

    The OWC does not administer or govern an organization's internal policies or procedures regarding utilization review. However, Insurance Carriers and self-insured payers may only use a Utilization Review determination processed through the Office of Workers' Compensation to deny a certified health care provider's payment for treatment that applies to one of the practice guidelines in the Delaware Workers' Compensation Health Care Payment System.

  29. How does the new law on utilization review affect the process at the OWC?


    30. The OWC issued two-year contracts to three utilization review (UR) organizations, which provide UR for applicable State of Delaware workers' compensation cases. Carriers or self-insured employers may file for utilization review through the Delaware Office of Workers' Compensation by following the administrative regulatory process for utilization review. The process is available by selecting "Utilization Review" from the menu located on the left side of this screen.

    We also encourage payers to contact the OWC's Medical Component at 302-761-8200 or hcpaymentquestions@state.de.us, if they need any extra guidance in preparing a Utilization Review Request.

    Pursuant to the Administrative Regulations for Utilization Review:

    "5.0 Utilization Review

    5.1 Pursuant to chapter 101, title 29 of the Delaware Code, the Department of Labor has developed a utilization review program with the intent of providing reference for employers, insurance carriers, and health care providers for evaluation of health care and charges. The intended purpose of utilization review services is to provide prompt resolution of issues related to treatment and/or compliance with the health care payment system or practice guidelines for those claims which have been acknowledged to be compensable.

    5.2 An employer or insurance carrier may engage in utilization review to evaluate the quality, reasonableness and/or necessity of proposed or provided health care services for acknowledged compensable claims. Any person conducting a utilization review program for workers' compensation shall be required to contract with the Office of Workers' Compensation once every two (2) years and certify compliance with Workers' Compensation Utilization Management Standards or Health Utilization Management Standards of Utilization Review Accreditation Council ("URAC") sufficient to achieve URAC accreditation or submit evidence of accreditation by URAC.

    5.3 At this time, Utilization Review is limited to health care recommendations subject to practice guidelines developed by the HCAP.

    5.4 An employer or insurance carrier may request utilization review by complying with all the terms and conditions set forth on the forms attached hereto. Upon completion and submission of the forms, information package and medical records package by the employer or insurance carrier, the designated utilization review company will review treatment to determine if it is in compliance with the practice guidelines developed by the Health Care Advisory Panel and adopted and implemented by the Department of Labor (See Appendix A).

    5.4.1 The utilization review company shall be randomly selected by the Department of Labor. The utilization review company first assigned to the case will remain with that case throughout its duration. The Department of Labor will collect all documentation required to be submitted pursuant to the utilization review process and send such documentation for review to the utilization review company.

    5.4.2 If the claim is denied by an employer or insurance carrier for non-compliance with any applicable Practice Guideline, only the first bill for such treatment, and not all subsequent bills for the same service, need be denied and referred to utilization review.

    5.4.3 All past, prospective and concurrent health care decisions must be reviewed and a Utilization Review determination made no later than three (3) working days from receipt of the aforementioned information, for emergency care, but no later than 15 calendar days from the date of the treatment recommended by the physician or less if set forth in URAC guidelines.

    5.5 If a party disagrees with the findings following utilization review, a petition may be filed with the Industrial Accident Board for de novo review.

    5.5.1 The decision of the utilization review company shall be forwarded by the Department of Labor, by Certified Mail, Return Receipt Requested, to the claimant, the health care provider in question, and the employer or its insurance carrier. A decision of the utilization review company shall be final and conclusive between the parties unless within 45 days from the date of receipt of the utilization review decision any interested party files a petition with the Industrial Accident Board for de novo review.

    5.6 If there are no current practice guidelines applicable to the health care provided, a party may file a petition with the Industrial Accident Board seeking a determination of the appropriateness of treatment."

  30. What date should be used to begin counting the number of occurrences when determining a Utilization Review (UR)?


    31. The Delaware Workers' Compensation Health Care Payment System (HCPS) became effective on 05-23-08. The Health Care Advisory Panel clarified that they expect Utilization Reviews under the HCPS to consider treatment, visits, etcetera that occurred on or after 05-23-08.

  31. What is the deadline for processing a Utilization Review (UR) request?


    32. The Office of Workers' Compensation must receive (clocked-in) a UR request within 15 days from the date of denial. Carriers and employers have 30 days to deny or pay a bill, and then 15 days from the date of that denial to request a UR. The total time required depends on the date the carrier or employer sent the denial; however, the total time may not exceed 45 days (30 days to pay or deny + 15 days to process UR = 45 total days). If the payer denies the bill prior to the 30 days specified in Title 19 Del. C. §2322F(h), then the payer still only has 15 days (clocked in at OWC) from that date to process the UR request.

    REFERENCES:
    Title 19 Del. C. §2322D
    Certification of health care providers.

    19 DE Admin. Code 1341 - Section 3.0
    Health Care Provider Certification

  32. Who has to become certified to treat injured workers?


    33. All providers who bill must be certified. The two modifications/exceptions are as follows:

    Hospital Modification: Providers treating an injured worker during his/her period of inpatient or outpatient hospitalization. In that circumstance, only physicians, chiropractors and physical therapists in the hospital setting need to be individually certified. All other personnel employed by a hospital providing treatment to an injured worker during his/her period of inpatient or out patient hospitalization are certified as a group by an authorized person/agent of the hospital.

    Emergency Room Exception: Services provided by an emergency department of a hospital pursuant to Title 19 Del.C. §2322B(8)(c) shall not be subject to the requirement of Certification.

  33. Does the DOL issue certification numbers to certified health care providers?


    34. No. All users may find the entire certified provider list on the Health Care Payment System (HCPS) web page, so the DOL decided not to issue certification numbers. The 6/1/09 revised Physicians Report of Workers' Compensation Injury ("Physician's Form") only asks for the health care provider's certification date and should be the only version of the form now used.

    REFERENCES:
    Title 19 Del. C. §2322E
    Development of consistent forms for health care providers.

    19 DE Admin. Code 1341 - Section 6.0
    Forms

  34. What CPT code should providers use for the physician's report (provider form) and what is the fee? When should physicians fill out the form?


    35. Use the CPT code 99080 for the physician's report (provider form). The fee for the report is $30. Physicians treating injured workers fill out the physician's report (provider form) at the first visit and at any subsequent visit where a significant change (or something the physician believes warrants reporting) occurs in the injured workers medical status. If the injured worker does not miss time, write "no lost time" on the form at the initial visit. When more than one physician treats an injured worker, only the physician most responsible for the patient's care would fill out the form.

  35. When should I fill out the provider or employer forms?


    36. Provider - For new patients, at the first visit since the new law went into effect on 5/23/08 and any time a change occurs that the physician feels is significant enough to report. For existing patients, fill out the form anytime a change occurs that the physician feels is significant enough to report. For instance, if an injured worker might now qualify for a modified duty position or if treatment drastically changes, the provider would fill out the form.

    Employer - Fill the form out for all injured workers. If the worker does not miss time, write on the form "No Lost Time."

    MISCELLANNEOUS

  36. How does HIPAA affect workers' compensation?


    37. The U.S. Department of Health and Human Services, Office of Civil Rights (OCR), administers the Health Insurance Portability and Accountability Act (HIPAA). It has issued guidelinespdf icon that indicate that covered providers may disclose health information to workers' compensation insurers, state administrators, employers, and other entities involved in the workers' compensation system, to the extent disclosure is necessary to comply with, or is required by, state law, or to obtain payment.

    The guidelines include a number of frequently asked questions. For more information, please contact the U.S. Department of Health and Human Services

  37. Are any injured workers exempt from coverage under the Delaware Workers' Compensation Act?


    38. Yes. For exemptions please refer to Delaware Code Title 19, Chapter 23, Sections 2307 and 2308.

    In addition, seaman, maritime workers, railroad workers and federal employees are covered under federal workers' compensation law. An injured worker covered under federal law would need to contact the appropriate federal office depending on the location of the work accident.

  38. Where can I find a list of the 7/6/09 changes to Title 19 Del.C. §2322?


    39. The Governor signed Senate Bill No. 38 into law on 7/6/09. Senate Bill No. 38 is incorporated into the Delaware Code. You may find at the link below a copy of Senate Bill No. 38, which lists the specific amendments to the law:

    http://legis.delaware.gov/LIS/LIS145.nsf/vwLegislation/SB+38?Opendocument

Last Updated: Monday October 19 2009
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