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OhioBWC - Basics: (Policy library) - File

InfoStation Document

Provider Reimbursement in Multiple Claims Policy

The purpose of this policy is to provide a method of appropriate reimbursement to medical providers who treat injured workers with multiple claims on the same date of service. BWC’s   states that a provider may be reimbursed for only one Evaluation and Management service per day, regardless of the number of claims being treated. The code is to be billed to the claim representing the chief complaint or reason for the visit.

 

Currently other services including osteopathic and chiropractic manipulative therapy and physical medicine procedures must also be billed in just one claim. Prior to mid-October 2003, providers were reimbursed in multiple claims for these procedures; however since that time, due to additional constraints built into BWC’s billing system, reimbursement for services in additional claims will be denied as duplicate.

 

Because of added physician administrative time when the physician must submit medical documentation for two or more claims, a request was made to allow additional reimbursement for some of the procedures.

 

Billing all treatment in one claim rather than dividing it between two or more claims could be perceived as fraudulent billing.

 

Policy/Procedures

A provider may be reimbursed for only one Evaluation and Management service per injured worker per day. Exceptions must be reviewed on a case by case basis. (Example: E/M service was provided in the morning, but due to an unforeseen problem, the injured worker had to return later in the day for a reason that would require another complete E/M service.)

 

If a provider is treating an injured worker with multiple claims, Evaluation and Management services may be billed in one claim only for each visit. The service should be billed to the claim representing the chief complaint or reason for the visit.

 

If multiple physicians provide Evaluation and Management services to an injured worker on a single day for conditions allowed in a claim, upon review of documentation, an MCO may reimburse each provider for the E/M service.

 

Osteopathic manipulative treatment

Additional reimbursement will not be made to cover administrative costs for billing in more than one claim.  Treatment will not be routinely reimbursed in more than two claims. Effective Sept. 1, 2004:

 

§  If one body region is allowed in each of two claims, each claim may be billed with CPT® 98925. For the primary or most significant claim, modifier PC must be added to the code. Modifier SC must be added to the code in the second claim.

 

§  If a total of three or four body regions are allowed and treated in two claims, two in one       claim and one or two in a second claim, each claim may be billed with 98926. For the primary or most significant claim, modifier PC must be added to the code. Modifier SC must be added to the code in the second claim.

 

§  If a total of five or six body regions are allowed and treated in two claims, each claim may be billed with 98927. For the primary or most significant claim, modifier PC must added to the   code. Modifier SC must be added to the code in the second claim.

 

Reimbursement for osteopathic manipulative treatment provided in two claims will be 50% of the BWC fee for each claim. Failure to use the modifiers in both claims will cause the second bill submitted to be denied as a duplicate. Osteopathic manipulative treatment billed in more than two claims on the same date of service will be denied.

 

Chiropractic manipulative treatment

Additional reimbursement will not be made to cover administrative costs for billing in more than            one claim. Treatment will not be routinely reimbursed in more than two claims. Effective Sept. 1, 2004

 

§  If one spinal region is allowed in each of two claims, each claim may be billed with CPT® 98940. For the primary or most significant claim, modifier PC must be added to the code. Modifier SC must be added to the code in the second claim.

 

§  If a total of three or four spinal regions are allowed and treated in two claims, two in one claim and one or two in a second claim, each claim may be billed with 98941. For the primary or most significant claim, modifier PC must be added to the code. Modifier SC must be added to the code in the second claim.

 

§  If a total of five spinal regions are allowed and treated in two claims, each claim may be billed with 98942. For the primary or most significant claim, modifier PC must be added to the code. The second claim must be billed with 98942 with modifier SC added to the code.

 

§  If at least one extraspinal region is allowed in each of two claims, each claim may be billed with CPT® 98943. For the primary or most significant claim, modifier PC must be added to the code. Modifier SC must be added to the code in the second claim

 

Reimbursement for chiropractic manipulative treatment provided in two claims will be 50% of the BWC fee for each claim.Failure to use the modifiers in both claims will cause the second bill submitted to be denied as a duplicate. Chiropractic manipulative treatment billed in more than two claims on the same date of service will be denied.

 

Physical medicine procedures

Effective Sept. 1, 2004

§  CPT® codes 97012 – 97028 are reimbursable in only one claim per date of service as these codes describe treatments to one or more areas without time specifications

 

§  CPT®   codes 97032 - 97530 may be reimbursed in only one claim if a total of  fifteen minutes or less are provided

 

§  CPT®   codes 97032 – 97530 may be reimbursed in more than one claim if the total time units for each service exceed one unit or fifteen minutes. For each fifteen minutes, one unit may be billed in each claim using modifier PT in the first claim and ST in the second claim. For example, CPT®  code 97110 – therapeutic exercises to develop strength and endurance are done for 30 minutes. If the injured worker has two claims, one unit can be billed in each.

 

Reimbursement for physical medicine procedures will be at the lesser of the provider charge, BWC’s maximum allowable rate or the MCO's negotiated rate for panel providers.

 


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