FREQUENTLY ASKED QUESTIONS
- Why do some codes have fees set for them and others don't? What does POC85 mean?
- What is a geozip?
- What is a modifier?
- Where can I find the "Correct Coding Policy Manual?"
- Where can I find the "Payment Guide to Global Days?"
- How are the fees adjusted each year?
- Does the fee schedule apply to medical treatments before May 23, 2008?
- Are there any services not subject to the fee schedule?
- Does the Delaware fee schedule address missed appointments?
- Should we pay medical bills according to our contract or the fee schedule?
- Is balance billing allowed?
- How do I pay bills where there are professional and technical components (PC/TC)?
- Should a medical provider send bills to the employer or the payer?
- What can I do if the payer won't pay me correctly?
- Is the interest on medical bills owed if the claim is disputed for valid reasons but later determined to be compensable?
- Must bills be submitted on certain forms?
- Can you tell me if I am calculating a bill correctly?
- Did the OWC adopt the new MS-DRGs?
- 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?
- How do I reimburse for an out-of-state treatment?
- When an ambulance travels from one geozip to another, which one should count for billing?
- How does the new law on utilization review affect the process at the OWC?
- How does HIPAA affect workers' compensation?
- 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?
- How and when is the fee schedule updated? Where can I find the Consumer Price Index--Urban, U.S. City Average, All Items, as published by the United States Bureau of Labor Statistics?
- How are HCPCS codes reimbursed?
- When should I fill out the provider or employer forms?
- Who has to become certified to treat injured workers?
- How do you reimburse for the pharmaceutical drugs and/or drugs listed on OWC Preferred Drug List?
- What is the dispensing fee for pharmaceutical drugs?
- How do we handle bilateral/multilateral procedures?
- How would a utilization review (UR) provider register to perform utilization review in Delaware?
- How do we reimburse assistant surgeons?
1. Why do some codes have fees set for them and others don't? What does POC85 mean?
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:
4.3.1 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.
4.3.2 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.
4.3.3 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?
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?
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?"
The OWC adopted the National
Correct Coding Initiative as the review standard for bundling edits:
- General Correct Coding Policies
- Anesthesia Services (CPT codes 00000-09999)
- Surgery: Integumentary System (CPT codes 10000-19999)
- Surgery: Musculoskeletal System (CPT codes 20000-29999)
- Surgery: Respiratory, Cardiovascular, Hemic, and Lymphatic Systems (CPT codes 30000-39999)
- Surgery: Digestive System (CPT codes 40000-49999)
- Surgery: Urinary, Male Genital, Female Genital, Maternity Care and Delivery Systems (CPT codes 50000-59999)
- Surgery: Endocrine, Nervous, Eye and Ocular Adnexa, Auditory Systems (CPT codes 60000-69999)
- Radiology Services (CPT codes 70000-79999)
- Pathology and Laboratory Services (CPT codes 80000-89999)
- Medicine, Evaluation and Management Services (CPT codes 90000-99999)
- Supplemental Services (HCPCS Level II codes A0000-V9999)
- Category III Codes (CPT codes 0001T-0099T)
5. Where can I find the "Payment Guide to Global Days?"
The Health Care Advisory Panel is currently working on this topic.
6. How are the fees adjusted each year?
Pursuant to Title 19 Del. C. §2322B(n), "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(c), "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(i)(2), "...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(h)(2) "...in accordance with the Consumer Price Index-Urban, U.S. City Average for Medical Care.
7. Does the fee schedule apply to medical treatments before May 23, 2008?
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.
8. Are there any services not subject to the fee schedule?
Yes.
Pursuant to Title 19 Del.C. §2322B(h)(3), "Services provided in an emergency department or a hospital, or any other facility
subject to the federal Emergency Medical Treatment and Active Labor Act, United States Code §1395dd, et seq., 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 pre-authorization of services, or the health care practice guidelines adopted pursuant to §2322C of this
title."
9. Does the Delaware fee schedule address missed appointments?
No. The fee schedule only applies to services actually rendered in the
treatment of an injured worker.
10. Should we pay medical bills according to our contract or the fee schedule?
Pursuant to Title 19 Del.C. §2322B(d), "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."
11. Is balance billing allowed?
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.
12. How do I pay bills where there are professional and technical
components (PC/TC)?
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.
13. Should a medical provider send bills to the employer or the payer?
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."
14. What can I do if the payer will not pay me correctly?
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:
"4.18.9 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.
4.18.10 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."
15. Is the interest on medical bills owed if the claim is disputed for valid reasons but later
determined to be compensable?
Pursuant to the Administrative Regulations for the Introduction & Fee Schedule Guidelines:
4.18.8 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.
4.18.9 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.
16. Must bills be submitted on certain forms?
The fee schedule does not dictate the type of billing forms used. (Our act and
rules do not require the latest CMS-1500 or UB-04 forms.) In the interest
of facilitating transactions, we do encourage providers to use standard billing
forms.
17. Can you tell me if I am calculating a bill correctly?
No. We can provide general answers, as listed on this web page, but we do not have
the resources to address individual calculations.
18. Did the OWC adopt the new MS-DRGs?
No. In the interest of facilitating transactions, we do encourage providers to use DRGs
19. 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?
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.
20. How do I reimburse for an out-of-state treatment?
Pursuant to Administrative Regulation 4.17 of the Introduction & Fee Schedule Guidelines,
"If any procedure, treatment or service is rendered outside of 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 Delaware's Workers' Compensation Act 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."
21. When an ambulance travels from one geozip to another, which one should count for billing?
The most common and universally accepted practice is to use the geozip of the
place where the patient was picked up.
22. How does the new law on utilization review affect the process at the OWC?
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 state 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.
Pursuant to the Administrative Regulations for Utilization Review:
5.1 Pursuant to (chapter 23, title 19) 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 register 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.
23. How does HIPAA affect workers' compensation?
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 guidelines
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
24. 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?
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.
25. How and when is the fee schedule updated? Where can I find the Consumer Price Index--Urban, U.S. City Average, All Items, as published by the United States Bureau of Labor Statistics?
The fee schedule is updated pursuant to Title 19 Del. C. §2322B, which includes more expanded and specific information than you will find in this answer. We recommend you read
this section to understand how and when the fee schedule updates. The law specifies the different criteria that applies to the different categories of service, such as hospitals,
Ambulatory Service Treatment Centers, Pharmacy, as well as other categories related to workers' compensation health care services. The law references the annual change in the
Consumer Price Index (CPI) for the fees related to some of the categories of service.
You can find this information at the Bureau of Labor Statistics webpage: http://data.bls.gov/cgi-bin/surveymost?cu
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."
26. How are HCPCS codes reimbursed?
Users can find HCPCS reimbursement amounts in the fee schedule.
27. When should I fill out the provider or employer forms?
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."
28. Who has to become certified to treat injured workers?
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(h)(3) shall not be subject to the requirement of Certification.
29. How do you reimburse for the pharmaceutical drugs and/or drugs listed on OWC Preferred Drug List?
Pursuant to the Administrative Regulations for the Introduction & Fee Schedule Guidelines:
4.14 Reimbursement for pharmacy services, prescription drugs and other pharmaceuticals is 100% of the Average Wholesale Price (AWP) as of
October 31, 2006. 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 provider whose billing is audited.
4.14.2 The payment system will be adjusted yearly from the date the Health Care Advisory Panel recommended adoption of the fee schedule,
November 14, 2007, and each year thereafter the Department of Labor shall make an automatic adjustment to the maximum payment for
pharmacy services, prescription drugs and other pharmaceuticals in effect in January of that year. The Department of Labor shall increase
or decrease the maximum payment by the percentage change of increase or decrease in the Consumer Price Index--Urban, U.S. City Average, All
Items, as published by the United States Bureau of Labor Statistics.
4.14.3 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 October 31, 2006, 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
30. What is the dispensing fee for pharmaceutical drugs?
The Delaware Workers' Compensation Health Care Payment System (HCPS) does not include a dispensing fee in the fee schedule at this time.
31. How do we handle bilateral/multilateral procedures?
The Health Care Advisory Panel (HCAP) is working on this issue. The only guidance available for bilateral/multilateral procedures at
this time involves the coding sources specified in Title 19 Del. C.§2322B(10), which states the following:
(10) Professional service fees developed in the health care payment system shall be determined in accordance with the following provisions:
a. 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.
b. 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.
c. 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.
d. 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.
e. 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.
32. How would a utilization review (UR) provider register to perform utilization review in Delaware?
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 HCAP plans to update Utilization Review regulation 5.2 in the near future.
33. How do we reimburse assistant surgeons?
Assistant surgeons are not included in the fee schedule at this time; however, the Health Care Advisory Panel plans to address this issue in the future. In the meantime, the
Workers' Compensation Act says that if the fee schedule does not specify something, the default fee is 85% of the actual charge.
Pursuant to Title 19 Del. C. §2322B (5), "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 at 85% of actual charge."
