Current through Reg. 49, No. 38; September 20, 2024
(a) Specific
provisions contained in the Labor Code or division rules, including this
chapter, take precedence over any conflicting provision adopted or used by the
Centers for Medicare and Medicaid Services (CMS) in administering the Medicare
program. Independent review organization decisions on medical necessity made in
accordance with Labor Code §413.031 and §
133.308 of this title, which are
made on a case-by-case basis, take precedence, in that case only, over any
division rules and Medicare payment policies.
(b) Payment policies relating to coding,
billing, and reporting for workers' compensation specific codes, services, and
programs are as follows:
(1) Health care
providers must bill their usual and customary charges using the most current
Level I Current Procedural Terminology (CPT) and Level II Healthcare Common
Procedure Coding System (HCPCS) codes. Health care providers must submit
medical bills in accordance with the Labor Code and division rules.
(2) Modifying circumstance must be identified
by use of the appropriate modifier following the appropriate Level I (CPT
codes) and Level II HCPCS codes. Where HCPCS modifiers apply, insurance
carriers must treat them in accordance with Medicare and Texas Medicaid rules.
In addition, division-specific modifiers are identified in subsection (f) of
this section. When two or more modifiers apply to a single HCPCS code, indicate
each modifier on the bill.
(3) A
10% incentive payment must be added to the maximum allowable reimbursement
(MAR) for services outlined in §§
134.220,
134.225,
134.235,
134.240,
134.250, and
134.260 of this title and
subsection (d) of this section that are performed in designated workers'
compensation underserved areas in accordance with §
134.2 of this title. However,
reimbursement for a missed appointment under §134.240 does not qualify for
the 10% incentive payment.
(4) Fees
established in §§
134.235,
134.240,
134.250, and
134.260 of this title will be:
(A) adjusted once by applying the Medicare
Economic Index (MEI) percentage adjustment factor for the period 2009 -
2024.
(B) adjusted annually by
applying the MEI percentage adjustment factor identified in
§134.203(c)(2).
(C) rounded to
whole dollars by dropping amounts under 50 cents and increasing amounts from 50
to 99 cents to the next dollar. For example, $1.39 becomes $1 and $2.50 becomes
$3.
(D) effective on January 1 of
each new calendar year.
(c) When there is a negotiated or contracted
amount that complies with Labor Code §
413.011, reimbursement
must be the negotiated or contracted amount that applies to the billed
services.
(d) When billing for
services in §§134.215, 134.220, 134.225, or 134.230, and there is no
negotiated or contracted amount that complies with Labor Code §
413.011, reimbursement
must be the least of the:
(1) MAR
amount;
(2) health care provider's
usual and customary charge; or
(3)
fair and reasonable amount consistent with the standards of §
134.1 of this title.
(e) For services provided under
§§134.235, 134.240, 134.250, or 134.260, health care providers must
bill and be reimbursed the MAR.
(f)
The following division modifiers must be used by health care providers billing
professional medical services for correct coding, reporting, billing, and
reimbursement of the procedure codes.
(1)
25--This modifier must be added to CPT code 99456 when the division ordered the
designated doctor to perform an examination of an injured employee with one or
more of the diagnoses listed in §127.130(b)(9)(B) - (I) of this
title.
(2) 52--This modifier must
be added to CPT code 99456 when the division ordered the designated doctor to
perform an examination of an injured employee, and the injured employee failed
to attend the examination.
(3) CA,
Commission on Accreditation of Rehabilitation Facilities (CARF) accredited
programs--This modifier must be used when a health care provider bills for a
return-to-work rehabilitation program that is CARF accredited.
(4) CP, chronic pain management program--This
modifier must be added to CPT code 97799 to indicate chronic pain management
program services were performed.
(5) FC, functional capacity--This modifier
must be added to CPT code 97750 when a functional capacity evaluation is
performed.
(6) MR, outpatient
medical rehabilitation program--This modifier must be added to CPT code 97799
to indicate outpatient medical rehabilitation program services were
performed.
(7) MI, multiple
impairment ratings--This modifier must be added to CPT code 99456 when the
designated doctor is required to complete multiple impairment ratings
calculations.
(8) NM, not at
maximum medical improvement (MMI)--This modifier must be added to the
appropriate MMI CPT code to indicate that the injured employee has not reached
MMI when the purpose of the examination was to determine MMI.
(9) VR, review report--This modifier must be
added to CPT code 99455 to indicate that the service was the treating doctor's
review of reports only.
(10) V3,
treating doctor evaluation of MMI--This modifier must be added to CPT code
99455 when the office visit level of service is equal to CPT code
99213.
(11) V4, treating doctor
evaluation of MMI--This modifier must be added to CPT code 99455 when the
office visit level of service is equal to CPT code 99214.
(12) V5, treating doctor evaluation of
MMI--This modifier must be added to CPT code 99455 when the office visit level
of service is equal to CPT code 99215.
(13) WC, work conditioning--This modifier
must be added to CPT codes 97545 and 97546 to indicate work conditioning was
performed.
(14) WH, work
hardening--This modifier must be added to CPT codes 97545 and 97546 to indicate
work hardening was performed.
(15)
W1, case management for treating doctor--This modifier must be added to the
appropriate case management billing code activities when performed by the
treating doctor.
(16) W5,
designated doctor examination for impairment or attainment of MMI--This
modifier must be added to the appropriate examination code performed by a
designated doctor when determining impairment caused by the compensable injury
and in attainment of MMI.
(17) W6,
designated doctor examination for extent--This modifier must be added to the
appropriate examination code performed by a designated doctor when determining
extent of the injured employee's compensable injury.
(18) W7, designated doctor examination for
disability--This modifier must be added to the appropriate examination code
performed by a designated doctor when determining whether the injured
employee's disability is a direct result of the work-related injury.
(19) W8, designated doctor examination for
return to work--This modifier must be added to the appropriate examination code
performed by a designated doctor when determining the ability of the injured
employee to return to work.
(20)
W9, designated doctor examination for other similar issues--This modifier must
be added to the appropriate examination code performed by a designated doctor
when determining other similar issues.
