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InfoStation Document

Use of EOB 776 Policy

 

Purpose

The goal of this policy is appropriate payment of billed services on the initial submission, using EOB 776 rather than inappropriately denying bills and delaying reimbursement.  This policy defines the override EOB 776, and clarifies when it should be used.

 

EOB 776 is an override explanation of benefits code which is defined as: payment is being made for a non-allowed, but related condition. The MCO must use the 776 override EOB if the MCO determines that it is appropriate to reimburse for treatment of a condition that is not allowed in a claim, and has supporting medical documentation to substantiate their determination to override and pay the bill.

 

Scope

This policy applies to all MCOs who are responsible for the reimbursement of medical service/supplies to all providers including hospitals, ambulatory surgery centers (ASC), physicians and non-physician providers and will address the appropriate and inappropriate use of EOB 776.

 

Appropriate use of EOB 776

 

Miller Criteria

MCOs formulate policies and procedures that govern provision of medical treatments and services, including either authorization or denial. The available medical evidence must not only support any decision, but also conform to law and legal precedent. One of the most significant legal requirements has been imposed by the case of State, ex rel. Miller v. Indus. Comm., 71 Ohio St. 3d 229 (1994). The Miller case mandates that a three-pronged test be applied when considering requests for authorization of workers’ compensation medical services. Requests are evaluated using a three-pronged test composed of the following:

·         The requested medical services are reasonably related to the industrial injury;

·         The requested services are reasonably necessary and appropriate for the treatment of the industrial injury (allowed conditions);

·         The costs of the services are medically reasonable. 

All three parts of the test must be met to authorize reimbursement of medical services.

 

Application of the Miller Criteria with EOB 776

·         The Miller must be applied on a request-by-request basis.

·         Subsequent court cases determined that Miller does not excuse the requirement for formal allowance of conditions. The most important factor in considering treatment requests for non-allowed conditions is whether the requested treatment is for a specific body part or psychiatric/psychological condition as opposed to a generalized condition.

·         When a specific treatment is requested for the allowed conditions in a claim, (such as diagnostic studies, treatment and/or rehabilitation for the specific allowed conditions in the claim), the "reasonably related" prong of the Miller test is satisfied.

·         When specific treatment is requested for non-allowed conditions in a claim, the "reasonably related" prong of the Miller test is satisfied if the services requested are:

o   for generalized condition(s) (e.g. diabetes, hypertension, obesity); and

o   treatment of the generalized condition(s) would have a positive impact on the treatment outcome of the allowed conditions in the claim.

·         When a specific treatment is requested for non-allowed conditions in a claim, and the services requested are for specific body part(s) or psychological/psychiatric condition(s), (such as meniscus tear, herniated disc, etc.) the "reasonably related" prong of the Miller test is NOT satisfied. Treatment should NOT be further considered for authorization unless the claim is additionally allowed for the specific body part(s) or psychological/psychiatric condition(s).

 

Ramifications of the Miller Case:

·         All medical evidence reviewed must be clearly documented in the V-3 claim notes showing that Miller criteria were applied (See section VIII Recommendations for detailed instructions)

·         Eligibility of services must be evaluated solely upon meeting the three pronged test. 

 

Special Considerations: 

·         The Miller criteria do not sanction approval of psychological treatment when there is not a psychological condition allowed in the claim. However, Miller must be applied to requests for psychological services when a psychological condition is allowed in the claim

·         MCOs shall also utilize the 776 EOB override when treatment not requiring prior approval is   provided and billed with a non-allowed ICD-9-CM code if the provider’s documentation supports that the treatment and the non-allowed condition is related to the allowed diagnosis.

 

Examples of appropriate use of EOB 776

1.    Treatment was authorized by an MCO based on Miller criteria for a condition not specifically allowed in the injured worker’s claim, but related to the allowed condition. If the ICD-9-CM code for the previously identified, related condition is submitted on the bill, the MCO shall use EOB 776.

a.    An injured worker develops a post-operative infection which may resolve within a few weeks.  Treatment could require oral and/or intravenous antibiotics. The bills should be paid using EOB 776.  If an injured worker develops a post-operative or post-injury condition such as osteomyelitis which would require long-term treatment, the MCO must pay the bills using EOB 776, but shall work with the customer service team regarding the need for the additional condition allowance.

 

b.    An injured worker develops post-operative complications such as deep vein thrombosis (DVT) or pulmonary embolism (PE) which could require re-hospitalization for anti-coagulation, placement of Greenfield filter, and nursing care for blood level of oral anti-coagulation medication management, rehabilitation, or assistance with activities of daily living. The MCO shall pay the related bills using EOB 776 and then work with the customer service team regarding the need for the additional claim allowance.

 

c.    An injured worker develops complications related to treatment for the allowed conditions; for example: injured worker has an adverse reaction to the medications prescribed for the treatment of the allowed conditions.  The related bills shall be paid using EOB 776. If the condition requires continuing treatment, the MCO shall work with the customer service team regarding the need for an additional claim allowance.

 

d.    An injured worker has a generalized condition such as diabetes or hypertension that is not an allowed claim condition. As a result of treatment/surgery for the allowed condition, the injured worker’s generalized condition is no longer under control. The MCO shall pay the related bills for the treatment of the generalized condition using EOB 776 until the generalized condition is stabilized.  However, if there is likely to be long term treatment of the complication that may later be considered to be related to the claim, a request for an additional allowance is probably necessary.  Payment for additional or more extensive treatment would be dependent on additional allowance and other factors in the claim.  This must be viewed on a case by case basis.

 

 

2.    BWC will accept valid V codes for the principal diagnosis on all bills. The MCO must utilize the EOB 776 override on all V code bills after the MCO performs an analysis confirming services meet the criteria of the Miller test.

 

a.    An injured worker requires pre-operative clearance for a surgical procedure where related conditions are being evaluated. The services may be billed with a V code, such as V72.82 Other specified pre-operative examination.  The MCO shall pay the bill using EOB 776.

 

b.    An injured worker received physical, occupational or speech therapy services related to an allowed claim condition.  The services are billed with a V code, such as V57.1 other physical therapy; V57.21 Encounter for occupational therapy; or V57.3 Speech therapy. The MCO shall pay the bill using EOB 776.

 

c.    An injured worker is receiving chemotherapy or radio-therapy for treatment of an allowed claim condition.  The services are billed with a V code, such as V 58.1 Encounter for antineoplastic chemotherapy and immunotherapy or V58.0 Radiotherapy.  The bill should be paid using EOB 776.

 

d.    The MCO authorizes a hospitalization for the removal of internal fixation device (surgical hardware) placed in a previous surgery to stabilize the injured worker’s allowed condition of fracture of the shaft of the femur, coded as 821.01.   Because hospitals code the diagnosis from the medical records for the current hospitalization, V54.01 Encounter for removal of internal fixation device, is listed  on the hospital bill as the diagnosis. V54.01 is not a match to the allowed claim condition, coded as 821.01.  The MCO shall  review the hospital record to determine if  the removal of the surgical hardware is related to the allowed claim condition, then pay the bill using EOB 776 if the review substantiates that the treatment was related to the allowed claim condition.

 

3.    Application of EOB 776 may be appropriate for services rendered when an injured worker has an allowed diagnosis and the injured worker has symptoms indicating that further diagnostic studies are necessary to determine if a more extensive work related injury (than previously believed) has occurred. The following expands upon O.A.C. 4123-6-31, and is also in Chapter 8 of the MCO Policy Reference Guide: Payment for x-ray examinations (including CT, MRI, and discogram) shall be made when medical evidence shows that the examination is medically necessary either for the treatment of an allowed injury or occupational disease, or for diagnostic purposes to pursue more specific diagnoses in a claim. Providers shall follow all bureau prior authorization policies in effect at the time when requesting authorization and payment for such studies. If a new condition is not found, but the diagnostic study  was related to the allowed claim condition and prior authorized by the MCO, the MCO should pay the bill utilizing EOB 776 if the ICD-9-CM  code is one that is not already allowed in the claim. If a new condition is found, however, the diagnostic service should be billed with the ICD-9-CM code for the new condition. For example:

 

a.    A claim is currently allowed for strain of the knee, coded as 844.9.  The injured worker has continued symptoms suggesting a more serious injury. The treating physician requests and receives authorization for a diagnostic arthroscopy of the knee. During the procedure, the physician notes a tear of the anterior cruciate ligament (ACL) and repairs the ligament.  The provider bills with the diagnostic code of 844.2  for the tear of the ACL.   The MCO shall reimburse the surgical arthroscopy, which includes repair of the torn ACL, using EOB 776. Services for further treatment for the new condition should not be paid, however, until the new condition is allowed in the claim. The MCO shall  contact the BWC customer service team regarding the need for the additional claim allowance.

 

b.    A claim is currently allowed for shoulder sprain coded as 840.8.  The injured worker has continued symptoms suggesting a more serious injury.  The treating physician orders an MRI which shows a tear of the rotator cuff. The provider bills for the MRI with the diagnosis of 840.4 for the tear of the rotator cuff.  The MCO shall reimburse for the diagnostic service with the ICD-9-CM code for the new condition using EOB 776. Services for further treatment for the new condition should not be paid, however, until the new condition is allowed in the claim.  The MCO shall contact the BWC customer service team regarding the need for the additional claim allowance.

 

4.    From time to time, the number of digits in an ICD-9-CM code is expanded. For example a three digit code may be expanded to four digits or a four digit code is expanded to five digits. The proper application of coding principles requires the highest level of specificity or maximum number of digits be assigned for a code. If an injured worker’s claim has been allowed for a condition that is identified by an ICD-9-CM that has been expanded subsequent to the claim allowance, the MCO must use the 776 EOB override if the provider bills with the current expanded code.

 

Inappropriate Use of EOB 776

The use of EOB 776 is prohibited when a condition is expressly disallowed in the injured worker’s claim.

 

The use of EOB 776 is not appropriate unless the MCO documents the following information:

·         The requested medical services are reasonably  related to the industrial injury (allowed conditions)

·         The requested medical services are reasonably necessary and appropriate for the treatment of the industrial injury (allowed conditions).

·         The costs of the services are medically reasonable.

 

1.    An injured worker has a generalized condition such as diabetes or hypertension that is not an  allowed claim condition.  The injured worker requires surgery for treatment of the allowed claim condition. Because the generalized condition is not under control, the injured worker cannot receive the surgery for the allowed claim condition. The MCO shall not pay the bills for the treatment of the generalized condition in this situation.  The use of EOB 776 is inappropriate.

 

2.    In an older claim, one that is more than 24 months from the original date of injury (DOI), which needs to be expanded:

 

a.    A 1987 claim was allowed for lumbar sprain (847.2). In 1989, the injured worker seeks treatment for severe back pain. The provider bills with the code 724.2, low back pain. However, the medical documentation from the physician gives a diagnosis of lumbar degenerative disc disease (722.52.) The claim is not allowed for degenerative disc disease (DDD) nor does DDD meet the Miller criteria. EOB 776 should not be applied. 

 

b.    A 2002 claim was allowed for tear of the medial meniscus and a sprain of the medial collateral ligament (ICD-9-CM codes 836.0 and 844.1). The injured worker received treatment in 2004 for diagnoses with chondromalacia of patella (ICD-9-CM code 717.7).  Chondromalacia has not been allowed in the claim; therefore, it is inappropriate to apply EOB 776 to pay this bill. The MCO shall  contact the BWC Customer Service Team if there is documentation to support adding chondromalacia as a claim allowance.

 

c.    A 1983 claim was allowed and successfully treated for a sprain of leg (844.9) and medial meniscus tear (836.0); the injured worker was evaluated and treated for arthritis (715.16) knee. The use of 776 to pay this bill  is inappropriate.

 

 

Unnecessary Use of EOB 776

There are instances when EOB 776 should not be applied.

 

A.   When the services are billed with an allowed condition in the claim

·         A claim is allowed for RSD of the lower limbs (337.22), unspecified RSD (337.20), and psychological conditions.   The MCO receives a bill for E/M services with ICD-9-CM of unspecified RSD (337.20).  The billed ICD-9-CM is an allowed condition in the claim, thus application of EOB 776 should not be applied.  No alternative EOB needed.

 

B.   When the services are billed with an ICD-9-CM code that is in the same ICD-9-CM group as the allowed condition(s). BWC groups ICD-9-CM codes into numeric sets called ICD-9-CM groups, which are found on BWC’s web site, ohiobwc.com. Injury or disease codes that are similar in nature or involve the same body part are grouped together. All ICD-9-CM codes in a given group are interchangeable and can be used for both allowance and reimbursement purposes.

·         A claim is allowed for conditions of the low back and psych condition of major depressive disorder, single episode, severe without mention of psychotic behaviour (296.23).   The MCO receives a bill for individual psychotherapy with ICD-9-CM of major depressive disorder, recurrent episode, severe without psychotic behaviour (296.33).  The billed ICD-9-CM is in the same ICD-9-CM group as the allowed psychological condition. (See MEN005 of the ICD-9-CM group document).  Use of EOB 776 was unnecessary as BWC’s billing system, CAMBRIDGE, would have automatically paid this bill. No alternative EOB needed.

·         A claim is allowed for sprain of the ankle (845.00) and knee (844.9.)  The MCO receives a bill for E/M services with ICD-9-CM of other ankle sprain (845.09).  The billed ICD-9-CM is in the same ICD-9-CM group (INJ114 of the ICD-9 group document.)  Application of EOB 776 was not necessary because BWC’s billing system, CAMBRIDGE, would have automatically paid this bill. No alternative EOB needed.

 

C. When services are rendered within 72 hours of date of injury:

·         An injured worker may seek treatment in an emergency room or physician’s office after an injury has occurred.  The specific conditions to be included in the claim are not known at the time the initial treatment was rendered. Once the claim is allowed, bills submitted for services rendered within the 72 hours of the date of injury and billed with a book valid ICD-9-CM code, will be paid by the Cambridge billing system.  The use of EOB 776 is inappropriate and should not be applied.


 

 

Recommendations

A.   The MCO shall use EOB 776 as defined in this policy for payment of bills for treatment of non-allowed conditions.

 

B.   Each use of EOB 776 override must be reviewed on a case by case basis.

 

C.   Prior to using EOB 776, the MCO shall perform the following steps:

·         Contact the provider for medical records, if not available

·         Obtain documentation and have imaged into claim file

·         Obtain a review of the medical documentation by the MCO nurse or coder who will enter a V-3 note into the claim file. The note shall document   the reviewer’s rationale for utilizing EOB 776, citing the specific documents used in the decision and an analysis of how the three prong Miller test was satisfied to justify payment of the medical services in the claim.

 

D.   The MCO shall not use EOB 776 based solely on the request of the provider. The MCO shall follow the steps as noted in recommendation “C” prior to using EOB 776.

 

E.   MCOs must not ask or require providers to change ICD-9-CM codes, but the MCO must contact the provider to ascertain whether there could be a billing or typographical error, or if a new condition is being requested, and communicate to the provider the possibility of bills submitted with non-allowed conditions being denied.

 

F.    Inappropriate use of EOB 776 may result in recovery from the MCO. The MCO may be responsible for payment for any services authorized by the MCO for an unrelated or disallowed diagnosis using override EOB 776.

 

G.   The application of EOB 776 will not allow payment of bills containing invalid ICD-9-CM codes (as listed in the BWC Invalid ICD-9 Codes document). The MCO must request an adjustment of the denied bill if the bill should be paid.

 

H.    Services provided for conditions not allowed in an injured worker’s claim are the responsibility of the injured worker.  However, if a bill is submitted with a diagnosis not allowed in the injured worker’s claim,  that does not automatically mean the injured worker should be billed. The MCO must explore with the provider the possibility that the claim allowance needs to be updated, perhaps proactively. If a proactive allowance is not appropriate, the CSS should contact the injured worker about submitting a C86 Motion request for an additional allowance. If the service is appropriate, but the provider or the provider’s billing personnel have made an ICD-9 or typographical error when billing, this can be discussed when contacting the provider’s office.

 

I.      . .In catastrophic (CAT), or settlement claims, it may be appropriate to use the EOB 776.The MCO shall place a V3 note in the claim stating the bill was paid pending settlement or as part of a CAT claim, and the reason use of EOB 776 is appropriate.

 

Measurements

BWC’s Medical Services Division will regularly monitor the usage of the EOB 776 override code for appropriateness and to ensure complete medical records were obtained and justification is documented in case notes.

 

 


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