01.
General
Provisions for Medical Fees. The following provisions shall apply to
Commission approval of claims for medical benefits. (3-23-22)
a. Acceptable Charge. Payors shall pay
Providers the acceptable charge for medical services. (3-23-22)
b. Coding. The Commission will generally
follow the coding guidelines published by CMS and by the American Medical
Association, including the use of modifiers. (3-23-22)
c. Disputes. Disputes between Providers and
Payors are governed by Subsection
803.06 of this rule and JRP 19.
(3-23-22)
d. Outside of Idaho.
Reimbursement for medical services provided outside the state of Idaho may be
based upon the agreement of the parties. If there is no agreement, services
shall be paid in accordance with the worker's compensation fee schedule in
effect in the state in which services are rendered. If there is no fee schedule
in effect in such state, or if the fee schedule in that state does not allow
reimbursement for the services rendered, reimbursement shall be paid in
accordance with these rules. (3-23-22)
02.
Acceptable Charges For Medical
Services Provided By Physicians Under The Idaho Worker's Compensation
Law. (3-23-22)
a. The Commission adopts
the RBRVS, published by CMS, as amended, as the standard to be used to
determine acceptable charges by physicians. (3-23-22)
b. Modifiers. Modifiers for physicians will
be reimbursed as follows: (3-23-22)
i.
Modifier 50: Additional fifty percent (50%) for bilateral procedure.
(3-23-22)
ii. Modifier 51: Fifty
percent (50%) of secondary procedure. This modifier will be applied to each
medical or surgical procedure rendered during the same session as the primary
procedure. (3-23-22)
iii. Modifier
80: Twenty-five percent (25%) of coded procedure. (3-23-22)
iv. Modifier 81: Fifteen percent (15%) of
coded procedure. This modifier applies to MD and non-MD assistants.
(3-23-22)
c. Conversion
Factors. The standard for determining the acceptable charge for a medical
service, identified by a code assigned to that service in the latest edition of
the Physician's CPT, published by the American Medical Association, as amended,
is calculated by the application of the total facility or non-facility RVU for
services as determined by place of service in the latest RBRVS in effect on the
first day of January of the current calendar year, to the following
corresponding conversion factors. The procedure with the largest RVU will be
the primary procedure and will be listed first on the claim form. (3-23-22)
MEDICAL FEE SCHEDULE |
SERVICE
CATEGORY |
CODE
RANGE(S) |
DESCRIPTION |
CONVERSION
FACTOR |
Anesthesia |
00000 - 09999 |
Anesthesia |
$60.33 |
Surgery - Group One |
22000 - 22999
23000 - 24999
25000 - 27299
27300 - 27999
29800 - 29999
61000 - 61999
62000 - 62259
63000 - 63999 |
Spine
Shoulder, Upper Arm, & Elbow
Forearm, Wrist, Hand, Pelvis & Hip
Leg, Knee, & Ankle
Endoscopy & Arthroscopy
Skull, Meninges & Brain
Repair, Neuroendoscopy & Shunts
Spine & Spinal Cord |
$135.00 |
Surgery - Group Two |
28000 - 28999
64550 - 64999 |
Foot & Toes
Nerves & Nervous System |
$124.00 |
Surgery - Group Three |
10000 - 19999
20000 - 21999
29000 - 29799
30000 - 39999
40000 - 49999
50000 - 59999
60000 - 60999
62260 - 62999
64000 - 64549
65000 - 69999 |
Integumentary System
Musculoskeletal System
Casts & Strapping
Respiratory & Cardiovascular
Digestive System
Urinary System
Endocrine System
Spine & Spinal Cord
Nerves & Nervous System
Eye & Ear |
$88.54 |
Radiology |
70000 - 79999 |
Radiology |
$88.54 |
Pathology & Laboratory |
80000 - 89999 |
Pathology & Laboratory |
To Be Determined |
Medicine - Group One |
90000 - 90749
94000 - 94999
97000 - 97799
97800 - 98999 |
Immunization, Injections, & Infusions
Pulmonary / Pulse Oximetry
Physical Medicine & Rehabilitation
Acupuncture, Osteopathy, &
Chiropractic |
$49.00 |
Medicine - Group Two |
90750 - 92999
93000 - 93999
95000 - 96020
96040 - 96999
99000 - 99607 |
Psychiatry & Medicine
Cardiography, Catheterization, Vascular
Studies
Allergy / Neuromuscular Procedures
Assessments & Special Procedures
E / M & Miscellaneous Services |
$70.00 |
(3-23-22)
d.
Anesthesiology. The Conversion Factor for the Anesthesiology CPT Codes shall be
multiplied by the current Anesthesia Base Units assigned to that CPT Code by
CMS, plus the allowable time units reported for the procedure. Time units are
computed by dividing reported time by fifteen (15) minutes. Time units will not
be used for CPT Code 01996. (3-23-22)
e. Services Without CPT Code, RVU or
Conversion Factor. The acceptable charge for medical services that do not have
a current CPT code, a currently assigned RVU, or a conversion factor will be
the reasonable charge for that service, based upon the usual and customary
charge and other relevant evidence, as determined by the Commission. Where a
service with a CPT Code, RVU, and conversion factor is, nonetheless, claimed to
be exceptional or unusual, the Commission may, notwithstanding the conversion
factor for that service set out in Paragraph 02.c, above, determine the
acceptable charge for that service, based on all relevant evidence in
accordance with the procedures set out in Subsection
06, below. (3-23-22)
f. Medicine Dispensed by Physicians.
Reimbursement to physicians for any medicine shall not exceed the acceptable
charge calculated for that medicine as if provided by a Pharmacy under
Subsection 04 of this rule without a dispensing
or compounding fee. Reimbursement to physicians for repackaged medicine shall
be the AWP for the medicine prior to repackaging, identified by the NDC
reported by the original manufacturer. Reimbursement may be withheld until the
original manufacturer's NDC is provided by the physician. (3-23-22)
g. Adjustment of Conversion Factors. The
conversion factors set out in this rule may be adjusted each fiscal year (FY)
by the Commission to reflect changes in inflation or market conditions in
accordance with Section
72-803, Idaho Code.
(3-23-22)
03.
Acceptable Charges For Medical Services Provided By Hospitals And
Ambulatory Surgery Centers Under The Idaho Worker's Compensation Law.
The following standards shall be used to determine the acceptable charge for
Hospitals and ASCs. (3-23-22)
a. Critical
Access Hospitals. The standard for determining the acceptable charge for
inpatient and outpatient services provided by a Critical Access Hospital is
ninety percent (90%) of the reasonable charge. Implantable hardware charges
shall be reimbursed at the rate of the actual cost plus fifty percent (50%).
(3-23-22)
b. Hospital Inpatient
Services. The standard for determining the acceptable charge for inpatient
services provided by Hospitals, other than Critical Access Hospitals, is
calculated by multiplying the base rate by the current MS-DRG weight for that
service. The base rate for inpatient services is ten thousand two hundred
dollars ($10,200). Inpatient services that do not have a relative weight shall
be paid at eighty-five percent (85%) of the reasonable charge; however,
Implantable Hardware charges billed for services without an MS-DRG weight shall
be reimbursed at the rate of actual cost plus fifty percent (50%).
(3-23-22)
c. Hospital Outpatient
and ASC Services. The standard for determining the acceptable charge for
outpatient services provided by Hospitals (other than Critical Access
Hospitals) and for services provided by ASCs is calculated by multiplying the
base rate by the Medicare Hospital Outpatient Prospective Payment System APC
weight in effect on the first day of January of the current calendar year. The
base rate for Hospital outpatient services is one hundred forty dollars and
seventy-five cents ($140.75). The base rate for ASC services is ninety-one
dollars fifty cents ($91.50). (3-23-22)
i.
Medical services for which there is no APC weight listed shall be reimbursed at
seventy-five percent (75%) of the reasonable charge. (3-23-22)
ii. Status code N items or items with no CPT
or HCPCS code shall receive no payment except as provided in Subparagraph
803.03.c.ii.(1) or 803.03.c.ii.(2) of this rule. (3-23-22)
(1) Implantable Hardware may be eligible for
separate payment under Subparagraph 03.d.iii. of this rule. (3-23-22)
(2) Outpatient laboratory tests provided with
no other Hospital outpatient service on the same date, or outpatient laboratory
tests provided on the same date of service as other Hospital outpatient
services that are clinically unrelated may be paid separately if billed with
modifier L1. Payment shall be made in the same manner that services with no APC
weight are paid under Subparagraph 803.03.c.i. of this rule.
(3-23-22)
iii. When no
medical services with a status code J1 appears on the same Claim, two (2) or
more medical procedures with a status code T on the same Claim shall be
reimbursed with the highest weighted code paid at one hundred percent (100%) of
the APC calculated amount and all other status code T items paid at fifty
percent (50%). When a medical service with a status code J1 appears on the same
Claim, all medical services with a status code T shall be paid at fifty percent
(50%). (3-23-22)
iv. When no
medical services with a status code J1 appears on the same Claim, status code Q
items with an assigned APC weight will not be discounted. When a medical
service with a status code J1 appears on the same Claim, status code Q items
shall be paid at fifty percent (50%). (3-23-22)
d. Additional Hospital Payments. When the
charge for a medical service provided by a Hospital (other than a Critical
Access Hospital) meets the following standards, additional payment shall be
made for that service, as indicated. (3-23-22)
i. Inpatient Threshold Exceeded. When the
charge for a Hospital inpatient MS-DRG coded service exceeds the sum of thirty
thousand dollars ($30,000) plus the payment calculated under the provisions of
Paragraph 03.b. of this rule, then the total payment for that service shall be
the sum of the MS-DRG payment and the amount charged above that threshold
multiplied by seventy-five percent (75%). Implantable charges shall be excluded
from the calculation for an additional inpatient payment under this
Subparagraph. (3-23-22)
ii.
Inpatient Implantable Hardware. Hospitals may seek additional reimbursement
beyond the MSDRG payment for invoiced Implantable Hardware where the aggregate
invoice cost is greater than ten thousand dollars ($10,000). Additional
reimbursement shall be the invoice cost plus an amount which is equal to ten
percent (10%) of the invoice cost, but which does not exceed three thousand
dollars ($3,000). Handling and freight charges shall be included in invoice
cost. (3-23-22)
iii. Outpatient
Implantable Hardware. Hospitals and ASCs may seek additional reimbursement
beyond the APC payment for invoiced Implantable Hardware where the aggregate
invoice cost is greater than five hundred dollars ($500). Additional
reimbursement shall be the invoice cost plus an amount which is equal to ten
percent (10%) of the invoice cost, but which does not exceed one thousand
dollars ($1,000). Handling and freight charges shall be included in invoice
cost. (3-23-22)
e.
Adjustment of Hospital and ASC Base Rates. The Commission may periodically
adjust the base rates set out in Paragraphs 803.03.b. and 803.03.c. of this
rule to reflect changes in inflation or market conditions.
(3-23-22)
04.
Acceptable Charges For Medicine Provided By Pharmacies. The following
standards shall be used to determine the acceptable charge for medicine
provided by pharmacies. (3-23-22)
a.
Brand/Trade Name Medicine. The standard for determining the acceptable charge
for brand/trade name medicine shall be the AWP, plus a five dollar ($5)
dispensing fee. (3-23-22)
b.
Generic Medicine. The standard for determining the acceptable charge for
generic medicine shall be the AWP, plus an eight dollar ($8) dispensing fee.
(3-23-22)
c. Compound Medicine. The
standard for determining the acceptable charge for compound medicine shall be
the sum of the AWP for each drug included in the compound medicine, plus a five
dollar ($5) dispensing fee and a two dollar ($2) compounding fee. All
components of the compound medicine shall be identified by their original
manufacturer's NDC when submitted for reimbursement. Payors may withhold
reimbursement until the original manufacturer's NDC assigned to each component
of the compound medicine is provided by the Pharmacy. Components of a compound
medicine without an NDC may require medical necessity confirmation by the
treating physician prior to reimbursement. (3-23-22)
d. Prescribed Over-the Counter Medicine. The
standard for determining the acceptable charge for prescribed over-the-counter
medicine filled by a Pharmacy shall be the reasonable charge plus a two dollar
($2) dispensing fee. (3-23-22)
05.
Acceptable Charges For Medical
Services Provided By Other Providers Under The Idaho Worker's Compensation
Law. The standard for determining the acceptable charge for Providers
other than physicians, Hospitals or ASCs shall be the reasonable charge.
(3-23-22)
06.
Billing And
Payment Requirements For Medical Services And Procedures Preliminary To Dispute
Resolution. This rule governs billing and payment requirements for
medical services provided under the Worker's Compensation Law and the
procedures for resolving disputes between Payors and Providers over those bills
or payments. (3-23-22)
a. Time Periods. None
of the periods herein shall begin to run before the Notice of Injury/Claim for
Benefits has been filed with the Employer as required by law.
(3-23-22)
b. Provider to Furnish
Information. A Provider, when submitting a bill to a Payor, shall inform the
Payor of the nature and extent of medical services furnished and for which the
bill is submitted. This information shall include, but is not limited to, the
patient's name, the employer's name, the date the medical service was provided,
the diagnosis, if any, and the amount of the charge or charges. Failure to
submit a bill complying with this Paragraph 06.b to the Payor within one
hundred twenty (120) days of the date of service will result in the
ineligibility of the Provider to utilize the dispute resolution procedures of
the Commission set out in Paragraph 803.06.i. of this rule for that service.
(3-23-22)
i. A Provider's bill shall, whenever
possible, describe the Medical Service provided, using the American Medical
Association's appropriate CPT coding, including modifiers, the appropriate
HCPCS code, the diagnostic and procedure code set version required by CMS and
the original NDC for the year in which the service was performed.
(3-23-22)
ii. The bill shall also
contain the name, address and telephone number of the individual the Payor may
contact in the event the Payor seeks additional information regarding the
Provider's bill. (3-23-22)
iii. If
requested by the Payor, the bill shall be accompanied by a written report as
defined by Subsection
010.31 and required by Section
404 of these rules. Where a bill is
not accompanied by such Report, the periods expressed in Paragraphs 803.06.c
and 803.06.e. of this rule, shall not begin to run until the Payor receives the
Report. (3-23-22)
c.
Prompt Payment. Unless the Payor denies liability for the Claim or, pursuant to
Paragraph 803.06.e. of this rule, sends a Preliminary Objection, a Request for
Clarification, or both, as to any charge, the Payor shall pay the charge within
thirty (30) calendar days of receipt of the bill or upon acceptance of
liability, if made after bill is received from Provider. (3-23-22)
d. Partial Payment. If the Payor acknowledges
liability for the Claim and, pursuant to Paragraph 803.06.e. of this rule,
sends a Preliminary Objection, a Request for Clarification, or both, as to only
part of a Provider's bill, the Payor must pay the charge or charges, or portion
thereof, as to which no Preliminary Objection or Request for Clarification has
been made, within thirty (30) calendar days of receipt of the bill.
(3-23-22)
e. Preliminary Objections
and Requests for Clarification. (3-23-22)
i.
Whenever a Payor objects to all or any part of a Provider's bill on the ground
that such bill contains a charge or charges that do not comport with the
applicable administrative rule, the Payor shall send a written Preliminary
Objection to the Provider within thirty (30) calendar days of the Payor's
receipt of the bill explaining the basis for each of the Payor's objections.
(3-23-22)
ii. Where the Payor
requires additional information, the Payor shall send a written Request for
Clarification to the Provider within thirty (30) calendar days of the Payor's
receipt of the bill, and shall specifically describe the information sought.
(3-23-22)
iii. Each Preliminary
Objection and Request for Clarification shall contain the name, address, and
phone number of the individual located within the state of Idaho that the
Provider may contact regarding the Preliminary Objection or Request for
Clarification. (3-23-22)
iv. Where
a Payor does not send a Preliminary Objection to a charge set forth in a bill
or a Request for Clarification within thirty (30) calendar days of receipt of
the bill, or provide an in-state contact in accord with Subparagraph 06.e.iii.,
it shall be precluded from objecting to such charge as failing to comport with
the applicable administrative rule. (3-23-22)
f. Provider Reply to Preliminary Objection or
Request for Clarification. (3-23-22)
i. Where
a Payor has timely sent a Preliminary Objection, Request for Clarification, or
both, the Provider shall send to the Payor a written Reply, if any it has,
within thirty (30) calendar days of the Provider's receipt of each Preliminary
Objection or Request for Clarification. (3-23-22)
ii. If a Provider fails to timely reply to a
Preliminary Objection, the Provider shall be deemed to have acquiesced in the
Payor's objection. (3-23-22)
iii.
If a Provider fails to timely reply to a Request for Clarification, the period
in which the Payor shall pay or issue a Final Objection shall not begin to run
until such clarification is received. (3-23-22)
g. Payor Shall Pay or Issue Final Objection.
The Payor shall pay the Provider's bill in whole or in part or send to the
Provider a written Final Objection, if any it has, to all or part of the bill
within thirty (30) calendar days of the Payor's receipt of the Reply.
(3-23-22)
h. Failure of Payor to
Finally Object. Where the Payor does not timely send a Final Objection to any
charge or portion thereof to which it continues to have an objection, it shall
be precluded from further objecting to such charge as unacceptable.
(3-23-22)
i. Dispute Resolution
Process. If, after completing the applicable steps set forth above, a Payor and
Provider are unable to agree on the appropriate charge for any Medical Service,
a Provider which has complied with the applicable requirements of this rule may
move the Commission to resolve the dispute as provided in the Judicial Rule Re:
Disputes Between Providers and Payors, as referenced in Paragraph 803.01.c. of
this rule. If Provider's motion disputing CPT or MS-DRG coded items prevails,
Payor shall pay the amount found by the Commission to be owed, plus an
additional thirty percent (30%) of that amount to compensate Provider for costs
and expenses associated with using the dispute resolution process. For motions
filed by a Provider disputing items without CPT or MS-DRG codes, the additional
thirty percent (30%) shall be due only if the Payor does not pay the amount
found due within thirty (30) days of the administrative order.
(3-23-22)