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OhioBWC - Basics:  Billing and Reimbursement Manual

Billing and Reimbursement

Billing and Reimbursement Manual
The Billing and Reimbursement Manual is BWC’s manual of provider reimbursement policies. This publication is updated quarterly and is typically referred to as the BRM.

E-Codes
There are two types of E-codes. One is part of the International Classification of Diseases (ICD-9) coding system, while the other is included in the Healthcare Common Procedural Coding System (HCPCS) Level II. It is important for medical providers to understand the distinctions between these codes.

ICD E-codes describe the mechanisms of injury. Examples of these codes include motor vehicle accidents, water transportation accidents and accidental poisonings. BWC does not accept ICD E-codes as a primary diagnosis; instead, a written description of the mechanism of injury is required. However, ICD E-codes can be accepted as a secondary ICD-9 only on inpatient bills.

HCPCS Level II E-codes are used for describing and billing durable medical equipment (DME). BWC accepts E-codes on both inpatient and outpatient bills.

Fee Schedule
The BWC provider fee schedule establishes the maximum reimbursement for medical treatments and services. The provider fee schedule, which is revised annually, is derived from the Resource Based Relative Value Scale reimbursement methodology.

Group Affiliations/Pay-to Number
Medical providers are sometimes affiliated with one or more group practices. When submitting bills to a third-party payor (such as BWC), these groups typically receive the reimbursement that is issued. In turn, the group compensates the servicing provider. To expedite reimbursement for services rendered to injured workers, a pay to provider (i.e., who should receive direct payment) and a servicing provider (i.e., the individual provider that treated the injured worker) must be identified on all medical bills.

Health Care Finance Administration (HCFA)
The Centers for Medicare and Medicaid Services (CMS), formerly know as the the Health Care Finance Administration (HCFA), is a federal agency that is part of the Department of Health and Human Services. CMS is responsible for a variety of national health-care functions, including the administration of Medicare and Medicaid, and the performance of regulatory and research functions impacting our nation's health-care system. Ohio's workers' compensation system relies on CMS to provide us with Resource Based Relative Value Scale (RBRVS) data for our provider fee schedule, research on quality measures and best practices, and nationally mandated standards, such as the Health Insurance Portability and Accountability Act (HIPAA).

Health Care Procedure Coding System (HCPCS)
The HCPCS is comprised of three levels of five-digit codes. Level I is used for reporting medical services and procedures; Level II is used for reporting durable medical equipment, dental vision and other services; and Level III is used for reporting services specific to Ohio workers’ compensation.

Inpatient and Outpatient Bills
Inpatient bills are bills submitted for reimbursement of services related to hospital stays (i.e., room charges, operating room, etc.). Outpatient bills are bills submitted for reimbursement of outpatient medical services (i.e., services not involving hospital admission, such as minor surgery). Use the nationally standardized UB-92 form or an electronic equivalent to submit inpatient and outpatient bills.

Managed Care Organization (MCO) Panel Amount
Under the Ohio Administrative Code, providers that belong to a MCO provider panel are reimbursed at the lesser of their billed charges, the BWC fee schedule amount, or the MCO panel amount. While MCOs do not establish fees, they can discount the BWC fee schedule amount for their panel providers, which the provider agrees to when a contract for panel participation is established.

Medical Bill
Medical bill is a broad term applied to all bills submitted to and received by BWC and the managed care organizations. Under Ohio workers’ compensation law, injured workers are entitled to payment of medical benefits, provided that their claims are allowed.

Payment
Payment is a broad term applied to all medical reimbursement issued by BWC and the managed care organizations, as well as to all compensation BWC issues to injured workers with lost-time claims. In all cases, payment of either medical or compensation is dependent upon BWC’s allowance of an injured worker’s claim.

Provider Bill Look-Up
The Provider bill look-up is a service offering available through BWC’s Web site. This service offering enables providers to view the status and amounts of all bills received by BWC.

Resource Based Relative Value Scale (RBRVS)
RBRVS is a nationally accepted medical provider reimbursement methodology. BWC uses RBRVS in its calculation of its provider fee schedule.

Remittance Advice
An itemized listing of bills paid or denied during the payment process.

Unbundle Charges
Unbundling charges is the practice of separating and billing for the individual components of a medical service rather than correctly billing with an all-inclusive procedure code. Unbundling is often done in error, although it is sometimes performed intentionally to maximize reimbursement. In either case, unbundling charges is strictly prohibited. Therefore, neither BWC nor the managed care organizations will reimburse for charges that have been unbundled.

V-Codes
There are two types of V-codes. One is part of the International Classification of Diseases (ICD) coding system, while the other is included in the Healthcare Common Procedural Coding System (HCPCS) Level II. It is important for medical providers to understand the distinctions between these codes.

ICD V-codes are codes used for describing circumstances that cannot be classified by using ICD codes 000 – 999. For billing purposes, BWC can accept V-codes as a principal diagnosis on inpatient and outpatient bills. Additionally, V-codes cannot be considered as conditions in the claim.

HCPCS Level II V-codes are used for describing and billing vision and hearing services. BWC accepts V codes on both inpatient and outpatient bills.



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