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Advisory 97-01

TEXAS WORKERS' COMPENSATION COMMISSION MEDICAL FEE GUIDELINE 1996, 28 TAC Section 134.201

Memo accompanying Advisory 97-01

June 13, 1997

TO: All Workers' Compensation Insurance Carriers, All Health Care Providers Billing for Workers' Compensation Services

Re: Texas Workers' Compensation Commission Medical Fee Guideline 1996

Dear Carrier or Health Care Provider:

The attached TWCC Advisory 97-01 contains clarifications of and clerical corrections to the TWCC Medical Fee Guideline 1996 (Medical Fee Guideline). These clarifications and clerical corrections are effective for all workers' compensation billing under the Medical Fee Guideline since its effective date of April 1, 1996.

If a health care provider (HCP) believes TWCC Advisory 97-01 affects the billing and reimbursement for medical services previously billed, the HCP may resubmit the bill to the insurance carrier in accordance with this lever. The Medical Review Division of the Commission will accept requests for medical dispute resolution for such resubmitted bills as set out in this letter. If the original bill covered medical services affected by TWCC Advisory 97-01 which were provided on or after April 1, 1996 through December 31, 1996, the Commission's Medical Review Division will accept a request for Medical Dispute Resolution of a bill resubmitted to the insurance carrier if the request is filed no later than January 1, 1998 and is otherwise in accordance with the Commission rule set out in Title 28 Texas Administrative Code Section 133.305. For any request for medical dispute resolution covering medical services affected by TWCC Advisory 97-01 provided on or after January 1, 1997, the Section 133.305 one-year filing deadline applies.

Except as specified in this notice, the Commission's dispute resolution staff will not consider requests for medical dispute resolution for resubmitted bills which should have been timely presented under Section 133.305, including medical justification for a deviation from the Guideline amounts. Medical disputes regarding medical services will be resolved in accordance with the provisions of the Texas Workers' Compensation Act, including Hose contained within Chapter 413 of the Texas Labor Code. Any party to a medical dispute resolution is responsible for submitting sufficient evidence in support of its position that the reimbursement amount sought meets the provisions of the Workers' Compensation Act and the Medical Fee Guideline.

Please direct any questions concerning these matters to the Commission's Medical Benefit Services staff at 512/707-5892.

Sincerely,

Todd K. Brown, Executive Director


Advisory 97-01


TEXAS WORKERS' COMPENSATION COMMISSION MEDICAL FEE GUIDELINE 1996, 28 TAC Section 134.201


The Commission provides this information to clarify certain provisions of the TWCC Medical Fee Guideline 1996, adopted by reference in 28 Texas Administrative Code Section 134.201 (Medical Fee Guideline).

Modifier -22 Unusual Services

The Medical Fee Guideline contains reimbursement amounts or methods to be used for reimbursement for health care provided under the Texas workers' compensation system. When a service is provided that is greater than that usually required for the listed procedure, the modifier -22 Unusual Services may be used to request reimbursement in excess of that specified in the Medical Fee Guideline. Documentation of procedure (DOP) substantiating the request for increased reimbursement is required.

Required Medical Examination (not for Maximum Medical Improvement/Impairment Rating)

When billing for a required medical examination that is not for the purpose of certifying maximum medical improvement or assessing an impairment rating (MMI/IR), a provider should use the appropriate CPT code describing the level of service with modifier -34 and bill the usual and customary charge for the examination.

Videofluoroscopy - Radiology/Nuclear Medicine Ground Rules I(D), page 204

For the purposes of the Medical-Fee Guideline, the term videofluoroscopy refers to the performance of a fluoroscopic procedure of which a video tape recording of that procedure is also generated. A video tape of the fluoroscope may be considered an appropriate legal precaution; however, it is very rarely considered a medical necessity. When videofluoroscopy or fluoroscopy is performed with a myelogram or discogram, such procedures are considered part of the service and should not be billed separately. If a hearth 'care provider believes fluoroscopic assistance (fluoroscope) is medically necessary when performing an injection on a particular patient, and it is not included in the procedure, the provider shall bill the appropriate CPT code for the injection and the appropriate CPT code for the fluoroscopic assistance. If a health care provider believes a video tape of the fluoroscopic assistance is medically necessary for a particular patient, the provider shall bill the appropriate CPT code for the injection and the appropriate CPT code for the fluoroscopic assistance with the addition of the modifier -22 Unusual Services for the video tape. For reimbursement of fluoroscopic assistance with the modifier -22 to be considered, the provider must include documentation of medical necessity.

Office Visit Charge for Therapeutic Procedures - Surgery Ground Rules I(E)(4)(e), page 66

When a therapeutic procedure, such as an injection, is performed at a follow-up office visit, a health care provider may additionally bill and be reimbursed for a minimal office visit in accordance with the CPT code descriptors in the Evaluation and Management section of the Medical Fee Guideline only when a significant reevaluation of the injured worker is necessary. To eliminate possible delays caused by return and resubmission of bills, the health care provider may wish to submit documentation supporting the necessity for reevaluation and the performance of a minimal office visit.

Charges for Emergency Room Visits - Surgery Ground Rules I(B)(1)(a), page 63

Physician charges for an emergency room visit may be billed and reimbursed when an injured worker is admitted to surgery through the emergency room if the emergency room visit is the initial visit and requires prolonged detention or evaluation in order to prepare the patient and/or to establish the need for a particular type of surgery. To eliminate possible delays caused by return and resubmission of bills, the health care provider may wish to submit documentation supporting reimbursement for an emergency room visit including documentation that the patient required prolonged detention or evaluation to prepare the patient for surgery and/or to establish the need for a particular type of surgery.

Services Necessary to Stabilize a Patient

If an injured worker has a condition (for example, diabetes) that impacts surgery or the treatment provided to the injured worker for a compensable injury, services necessary to stabilize the patient, so that surgery or other treatment of the compensable injury can be performed safely and/or effectively, are reimbursable (in addition to the surgery or treatment) as provided by the Medical Fee Guideline for that service.

Billing for Immunizations - Medicine Ground Rules, page 45

The cost of drugs necessary for immunizations described by CPT codes 90700 through 90749 is billable separately and reimbursable in addition to the fee provided by the Medical Fee Guideline for the immunization procedure.

Corrections of Clerical Errors in the Medical Fee Guideline 1996

The TWCC executive director has corrected the following clerical errors in the Commission's order of February 15, 1996 adopting and incorporating the Medical Fee Guideline 1996. The corrections and a brief explanation of their effect follows.

General Instructions, Section VIII(B), General Modifiers. page 3

Modifier -35 Designated Doctor - This modifier was included by clerical error and has been deleted.

The section of the proposed Medical Fee Guideline that referred to this modifier was deleted prior to adoption of the rule and modifier -35 is not used elsewhere in the Guideline.

General Instructions, Section VIII(C), Surgery Modifiers, page 4

The words "requiring a separate incision" should have been deleted when this modifier was revised to apply to procedures through both the same and separate incisions.

As corrected it reads: "-50 Bilateral Procedure: When bilateral procedures are performed at the same operative session, use the appropriate procedure code for the first procedure. For the second (bilateral) procedure, add the modifier "-50" to the procedure."

When a CPT code identifies half of a bilateral procedure, the second half of the procedure is identified by using that CPT code and the modifier -50. Health care providers should refer to the American Medical Association's 1995 Physicians' Current Procedural Terminology for additional information on billing bilateral procedures.

Surgery Ground Rules, Section I(E)(2)(a), Arthrodesis, page 65

The word "minimal" was omitted from the section by clerical error.

As corrected it reads: "All arthrodesis procedures include those vertebral graft preparations, such as minimal diskectomy, necessary to accomplish the arthrodesis."

Preparation of the arthrodesis site, such as minimal diskectomy, is not separately billable and is considered to be part of the arthrodesis procedure. A full diskectomy procedure may be billed separately if not included as part of the global procedure for arthrodesis. Refer to Global Service Data for Orthopaedic Surgery, revised edition, January 1994, compiled by the American Academy of Orthopaedic Surgeons for services excluded and included in the arthodesis procedure performed.

Surgery Ground Rules, Section I(E)(3), Bilateral Procedures, page 65

The phrase "unless otherwise identified in the CPT descriptor" should have been separated from subsection I(E)(3)(a) to indicate that it applies to both I(E)(3)(a) and (b).

As corrected it reads: "Unless otherwise identified in the CPT descriptor:

  1. Bilateral procedures that are performed at the same operative session shall be identified by the appropriate five digit code describing the firm procedure. The second (bilateral) procedure is identified by adding modifier -50 to the procedure.
  2. Fusions, instrumentations, and/or nerve decompression procedures are considered bilateral, therefore, no additional reimbursement shall be allowed."

Some CPT codes for bilateral procedures identify both sides of the procedure, whereas other CPT codes identify only half of the bilateral procedure. When a CPT code identifies half of a bilateral procedure, the second half of the bilateral procedure is identified by using the CPT code and the modifier -50. When a CPT code identifies both portions of a bilateral procedure, only one code is to be billed and reimbursed.

Health care providers should refer to the American Medical Association's 1995 Physicians' Current Procedural Terminology for additional information on billing bilateral procedures.

Surgery Ground Rules, Section I(E)(4)(c), Surgical Injections, page 66

The phrase "for lumbar or caudal epidural area" was omitted from the end of the sentence.

As corrected it reads: "Epidural steroid injections shall be billed using code 62289 only for lumbar or caudal epidural areas."

When an epidural steroid injection is performed outside of the lumbar or caudal areas, the appropriate CPT code should be used describing the service performed.

Surgery Ground Rules, Modifiers, page 68

The words "requiring a separate incision" should have been deleted when this modifier was revised to apply to procedures through both the same and separate incisions.

As corrected it reads: "-50 Bilateral Procedure: When bilateral procedures are performed at the same operative session, use the appropriate procedure code for the first procedure. For the second (bilateral) procedure, add the modifier "-50" to the procedure."

When a CPT code identifies half of a bilateral procedure, the second half of the procedure is identified by using the CPT code and the modifier -50. Health care providers should refer to the American Medical Association's 1995 Physicians' Current Procedural Terminology for additional information on billing bilateral procedures.

Corrections of Clerical Errors in Commission Order

The following are clerical errors which are contained in the Commission's order of February 15, 1996 adopting and incorporating the TWCC Medical Fee Guideline, 1996, 28 TAC Section 134.201. Pursuant to Texas Labor Code Section 402.042, these clerical errors are hereby corrected as follows.

General Instructions, Section VIII(B), General Modifiers, page 3

Modifier -35 Designated Doctor - This modifier was included by clerical error and is deleted.

General Instructions, Section VIII(C), Surgery Modifiers, page 4

The words "requiring a separate incision" should have been deleted when this modifier was revised to apply to procedures through both the same and separate incisions.

As corrected it reads: "-50 Bilateral Procedure: When bilateral procedures are performed at the same operative session, used the appropriate procedure code for the first procedure. For the second (bilateral) procedure, add the modifier "-50" to the procedure."

Surgery Ground Rules, Section I(E)(2)(a), page 65

The word "minimal" was omitted from the section.

As corrected it reads: "All arthordesis procedures include those vertebral graft preparations, such as minimal diskectomy, necessary to accomplish the arthrodesis."

Surgery Ground Rules, Section I(E)(3), page 65

The phrase "unless otherwise identified in the CPT descriptor" should have been separated from subsection I(E)(3)(a) to indicate that it applies to both I(E)(3)(a) and (b).

As corrected it reads: "Unless otherwise identified in the CPT descriptor:

  1. Bilateral procedures that are performed at the same operative session shall be identified by the appropriate five digit code describing the first procedure. The second (bilateral) procedure is identified by adding modifier -50 to the procedure.
  2. Fusions, instrumentations, and/or nerve decompression procedures are considered bilateral, therefore, no additional reimbursement shall be allowed"

Surgery Ground Rules, Section I(E)(4)(c), page 66

The phrase "for lumbar or caudal epidural area" was omitted from the end of the sentence by clerical error.

As corrected it reads: "Epidural steroid injections shall be billed using code 62289 only for lumbar or caudal epidural areas."

Surgery Ground Rules, Modifiers, page 68

The words "requiring a separate incision" should have been deleted when this modifier was revised to apply to procedures through both the same and separate incisions.

As corrected it reads: "-50 Bilateral Procedure: When bilateral procedures are performed at the same operative session, use the appropriate procedure code for the first procedure. For the second (bilateral) procedure, add the modifier "-50" to the procedure."

Signed June 13, 1997

Todd K. Brown, Executive Director



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