Current through Reg. 49, No. 38; September 20, 2024
(a) Applicability of this rule is as follows:
(1) This section applies to professional
medical services provided in the Texas workers' compensation system, other
than:
(A) workers' compensation specific
codes, services, and programs described in §
134.204
of this title (relating to Medical Fee Guideline for Workers' Compensation
Specific Services);
(B)
prescription drugs or medicine;
(C)
dental services;
(D) the facility
services of a hospital or other health care facility; and
(E) medical services provided through a
workers' compensation health care network certified pursuant to Insurance Code
Chapter 1305, except as provided in Insurance Code Chapter 1305.
(2) This section applies to
professional medical services provided on or after March 1, 2008.
(3) For professional services provided
between August 1, 2003 and March 1, 2008, §134.202
of this title (relating to Medical Fee Guideline) applies.
(4) For professional services provided prior
to August 1, 2003, §
134.201
of this title (relating to Medical Fee Guideline for Medical Treatments and
Services Provided under the Texas Workers' Compensation Act) and §134.302
of this title (relating to Dental Fee Guideline) apply.
(5) "Medicare payment policies" when used in
this section, shall mean reimbursement methodologies, models, and values or
weights including its coding, billing, and reporting payment policies as set
forth in the Centers for Medicare and Medicaid Services (CMS) payment policies
specific to Medicare.
(6)
Notwithstanding Medicare payment policies, chiropractors may be reimbursed for
services provided within the scope of their practice act.
(7) Specific provisions contained in the
Texas Labor Code or the Texas Department of Insurance, Division of Workers'
Compensation (Division) rules, including this chapter, shall take precedence
over any conflicting provision adopted or utilized by CMS in administering the
Medicare program. Independent Review Organization (IRO) decisions regarding
medical necessity made in accordance with Labor Code §
413.031
and § 133.308 of this title (relating to MDR by Independent Review
Organizations), which are made on a case-by-case basis, take precedence in that
case only, over any Division rules and Medicare payment policies.
(8) Whenever a component of the Medicare
program is revised, use of the revised component shall be required for
compliance with Division rules, decisions, and orders for professional services
rendered on or after the effective date, or after the effective date or the
adoption date of the revised component, whichever is later.
(b) For coding, billing,
reporting, and reimbursement of professional medical services, Texas workers'
compensation system participants shall apply the following:
(1) Medicare payment policies, including its
coding; billing; correct coding initiatives (CCI) edits; modifiers; bonus
payments for health professional shortage areas (HPSAs) and physician scarcity
areas (PSAs); and other payment policies in effect on the date a service is
provided with any additions or exceptions in the rules.
(2) A 10 percent incentive payment shall be
added to the maximum allowable reimbursement (MAR) for services outlined in
subsections (c) - (f) and (h) of this section that are performed in designated
workers' compensation underserved areas in accordance with §
134.2
of this title (relating to Incentive Payments for Workers' Compensation
Underserved Areas).
(c)
To determine the MAR for professional services, system participants shall apply
the Medicare payment policies with minimal modifications.
(1) For service categories of Evaluation
& Management, General Medicine, Physical Medicine and Rehabilitation,
Radiology, Pathology, Anesthesia, and Surgery when performed in an office
setting, the established conversion factor to be applied is $52.83. For Surgery
when performed in a facility setting, the established conversion factor to be
applied is $66.32.
(2) The
conversion factors listed in paragraph (1) of this subsection shall be the
conversion factors for calendar year 2008. Subsequent year's conversion factors
shall be determined by applying the annual percentage adjustment of the
Medicare Economic Index (MEI) to the previous year's conversion factors, and
shall be effective January 1st of the new calendar year. The following
hypothetical example illustrates this annual adjustment activity if the
Division had been using this MEI annual percentage adjustment: The 2006
Division conversion factor of $50.83 (with the exception of surgery) would have
been multiplied by the 2007 MEI annual percentage increase of 2.1 percent,
resulting in the $51.90 (with the exception of surgery) Division conversion
factor in 2007.
(d) The
MAR for Healthcare Common Procedure Coding System (HCPCS) Level II codes A, E,
J, K, and L shall be determined as follows:
(1) 125 percent of the fee listed for the
code in the Medicare Durable Medical Equipment, Prosthetics, Orthotics and
Supplies (DMEPOS) fee schedule;
(2)
if the code has no published Medicare rate, 125 percent of the published Texas
Medicaid fee schedule, durable medical equipment (DME)/medical supplies, for
HCPCS; or
(3) if neither paragraph
(1) nor (2) of this subsection apply, then as calculated according to
subsection (f) of this section.
(e) The MAR for pathology and laboratory
services not addressed in subsection (c)(1) of this section or in other
Division rules shall be determined as follows:
(1) 125 percent of the fee listed for the
code in the Medicare Clinical Fee Schedule for the technical component of the
service; and,
(2) 45 percent of the
Division established MAR for the code derived in paragraph (1) of this
subsection for the professional component of the service.
(f) For products and services for which no
relative value unit or payment has been assigned by Medicare, Texas Medicaid as
set forth in § 134.203(d) or §
134.204(f)
of this title, or the Division, reimbursement shall be provided in accordance
with §
134.1 of
this title (relating to Medical Reimbursement).
(g) When there is a negotiated or contracted
amount that complies with Labor Code §
413.011,
reimbursement shall be the negotiated or contracted amount that applies to the
billed services.
(h) When there is
no negotiated or contracted amount that complies with Labor Code §
413.011,
reimbursement shall be the least of the:
(1)
MAR amount;
(2) health care
provider's usual and customary charge, unless directed by Division rule to bill
a specific amount; or
(3) fair and
reasonable amount consistent with the standards of §
134.1 of
this title.
(i) Health
care providers (HCPs) shall bill their usual and customary charges using the
most current Level I (CPT codes) and Level II HCPCS codes. HCPs shall submit
medical bills in accordance with the Labor Code and Division rules.
(j) Modifying circumstance shall be
identified by use of the appropriate modifier following the appropriate Level I
(CPT codes) and Level II HCPCS codes. Division-specific modifiers are
identified and shall be applied in accordance with §
134.204(n)
of this title (relating to Medical Fee Guideline for Workers' Compensation
Specific Services). When two or more modifiers are applicable to a single CPT
code, indicate each modifier on the bill.
