Current through Reg. 49, No. 38; September 20, 2024
The following shall be applied to Return To Work
Rehabilitation Programs for billing and reimbursement of Work
Conditioning/General Occupational Rehabilitation Programs, Work
Hardening/Comprehensive Occupational Rehabilitation Programs, Chronic Pain
Management/Interdisciplinary Pain Rehabilitation Programs, and Outpatient
Medical Rehabilitation Programs. To qualify as a division Return to Work
Rehabilitation Program, a program should meet the specific program standards
for the program as listed in the most recent Commission on Accreditation of
Rehabilitation Facilities (CARF) Medical Rehabilitation Standards Manual, which
includes active participation in recovery and return to work planning by the
injured employee, employer and payor or insurance carrier.
(1) Accreditation by the CARF is recommended,
but not required.
(A) If the program is CARF
accredited, modifier "CA" shall follow the appropriate program modifier as
designated for the specific programs listed below. The hourly reimbursement for
a CARF accredited program shall be 100 percent of the maximum allowable
reimbursement (MAR).
(B) If the
program is not CARF accredited, the only modifier required is the appropriate
program modifier. The hourly reimbursement for a non-CARF accredited program
shall be 80 percent of the MAR.
(2) For division purposes, General
Occupational Rehabilitation Programs, as defined in the CARF manual, are
considered Work Conditioning.
(A) The first
two hours of each session shall be billed and reimbursed as one unit, using CPT
code 97545 with modifier "WC." Each additional hour shall be billed using CPT
code 97546 with modifier "WC." CARF accredited programs shall add "CA" as a
second modifier.
(B) Reimbursement
shall be $36 per hour. Units of less than one hour shall be prorated by 15
minute increments. A single 15 minute increment may be billed and reimbursed if
greater than or equal to eight minutes and less than 23 minutes.
(3) For division purposes,
Comprehensive Occupational Rehabilitation Programs, as defined in the CARF
manual, are considered Work Hardening.
(A)
The first two hours of each session shall be billed and reimbursed as one unit,
using CPT code 97545 with modifier "WH." Each additional hour shall be billed
using CPT code 97546 with modifier "WH." CARF accredited programs shall add
"CA" as a second modifier.
(B)
Reimbursement shall be $64 per hour. Units of less than one hour shall be
prorated by 15 minute increments. A single 15 minute increment may be billed
and reimbursed if greater than or equal to eight minutes and less than 23
minutes.
(4) The
following shall be applied for billing and reimbursement of Outpatient Medical
Rehabilitation Programs.
(A) Program shall be
billed and reimbursed using CPT code 97799 with modifier "MR" for each hour.
The number of hours shall be indicated in the units column on the bill. CARF
accredited programs shall add "CA" as a second modifier.
(B) Reimbursement shall be $90 per hour.
Units of less than one hour shall be prorated by 15 minute increments. A single
15 minute increment may be billed and reimbursed if greater than or equal to
eight minutes and less than 23 minutes.
(5) The following shall be applied for
billing and reimbursement of Chronic Pain Management/Interdisciplinary Pain
Rehabilitation Programs.
(A) Program shall be
billed and reimbursed using CPT code 97799 with modifier "CP" for each hour.
The number of hours shall be indicated in the units column on the bill. CARF
accredited programs shall add "CA" as a second modifier.
(B) Reimbursement shall be $125 per hour.
Units of less than one hour shall be prorated in 15 minute increments. A single
15 minute increment may be billed and reimbursed if greater than or equal to
eight minutes and less than 23 minutes.
