Clarification on Electronic Billing, and Other Updates

Saturday, April 22, 2006 | 0

The Division of Workers' Compensation (DWC) has clarified the billing and reimbursement of chiropractic treatment. The clarification, which was included in the February 2006 edition of the DWC's Healthcare Technical Update, noted that the current procedural terminology (CPT) codes for chiropractic manipulative treatment (CMT) includes the assessment of the patient as part of the CMT.

The DWC said a health care provider may not separately bill an insurer for an evaluation and management (E/M) service using the modifier - 25 except when a patient's condition clearly requires a substantial independently identifiable E/M service beyond the pre-service and post-service care normally provided as par of the CMT.

The Healthcare Technical Update noted that when an additional E/M service is required for the same symptoms or condition as the basic CMT, separate diagnoses are not required for billing. The DWC said this billing policy applies even when the CMT and E/M services are provided on the same date. Any specific CMT, e.g. one with a specific CPT code, performed on either the same or a later date as any E/M services must be reported separately. The health care provider should include with the E/M bill all documentation necessary to sufficiently justify the appropriateness of the E/M service.

The DWC pointed out that CMT codes are not included in the range of physical medicine and rehabilitation CPT codes and therefore do not require preauthorization.

The February 2006 edition of the Healthcare Technical Update also included clarification about the billing and reimbursement of CPT code 98943 (extraspinal manipulation). The bulletin noted that the Centers for Medicare & Medicare Services (CMS) only allows chiropractors to be reimbursed for correction of spinal subluxation - current procedural terminology (CPT) codes 98940, 98941, and 98942. CMS payment policies do not provide for the reimbursement of extraspinal manipula-tion (CPT code 98943).

The Healthcare Technical Update noted that the DWC's Medical Fee Guideline provides for the reimbursement of extraspinal manipulation (CPT code 98943), as well as spinal subluxation billed using CPT codes 98940, 98941, and 98942. The DWC noted that this divergence from the CMS payment policy is provided for by Rule 134.202(a)(3) which states "not withstanding Centers for Medicare and Medicaid Services (CMS) payment policies, chiropractors may be reimbursed for services provided within the scope of their practice act."

The update also noted that CPT code 98943 is not a "timed" code but does include one or more regions - the head, lower extremities, upper extremities, rib cage, and abdomen. Only one unit per day of CPT code 98943 may be billed and reimbursed, regardless of how many regions were mani-pulated or how much time was spent providing the chiropractic treatment. Insurers should refer to Subsection (c)(6) of the Medical Fee Guideline when reimbursing CPT code 98943 since the code has no specific established CMS or DWC reimbursement value.

The Division of Workers' Compensation Publishes Medical Benefit "Fast Facts" Publications

The Division of Workers' Compensation (DWC) has developed a series of "Fast Facts" publications that provide system participants with specific information on various workers' compensation medical benefits issues in a very user friendly question and answer format.

The "Fast Facts" developed to date address the following topics:

* Financial Disclosure requirements for doctors applying to be included on the DWC's Approved Doctor List;

* Medical Forms;

* Pharmacy issues;

* Preauthorization, Concurrent Review, and Voluntary Certification; and

* Prospective Review of Medical Care Not Requiring Pre-authorization.

The "Fast Facts" publications are available at the following Division of Workers' Compensation website link:http://www.tdi.state.tx.us/wc/dwc/divisions/medrev.html#fastfacts. DWC Publishes Updated List of Texas Certified Self-Insurers' Third-Party Administrators and Austin Representatives

On February 17, 2006, the Division of Workers' Compensation (DWC) published an updated list of Texas certified self-insurers' third-party administrators and Austin representatives. The list includes contact information for certified self-insurers, the self-insurers' third-party administrator, and the self-insurers' Austin representative. Austin representatives are designated by the self-insured companies as the agent to receive notices, decisions, and other important documents from the DWC.

There are 49 employers that currently hold self-insurance certifications issued by the Division of Workers' Compensation.

The updated list of Texas certified self-insurers' third-party administrators and Austin representatives is available at: http://www.tdi.state.tx.us/wc/dwc/divisions/selfinsurlist.html.



Article republished with the permission of the Insurance Council of Texas. www.insurancecouncil.org

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