Information for Medical Providers

Important News Regarding Ambulatory Surgery Fee Schedule
Rules and Public Comment Meeting on September 26, 2016

On August 9, 2016, Superior Court Judge Paul Ridgeway entered a Decision invalidating the ambulatory surgery center provisions of the workers’ compensation medical fee schedule that became effective April 1, 2015. Please click here to read that decision.

The Industrial Commission will hold a non-mandatory public comment meeting on September 26, 2016, to consider appropriate steps for the Industrial Commission to take in light of the August 9, 2016 Decision. Please click here to view the meeting notice.

ICD-10 Diagnosis Codes Required as of October 1, 2015

Beginning October 1, 2015, pursuant to N.C. Gen. Stat. § 97-26(g1) and in alignment with federal regulations, the applicable administrative standard for diagnosis code sets for medical billing and reporting in North Carolina workers’ compensation cases will transition to the International Classification of Diseases, 10th Edition, Clinical Modification and Procedure Coding System (ICD-10), from the 9th Edition (ICD-9).

Although there have been previous delays in the implementation of the ICD-10 code sets, the Industrial Commission will continue to follow the timeframe set by the Centers for Medicare and Medicaid Services (CMS).

All medical services provided on or after October 1, 2015, must be billed with ICD-10 diagnosis and procedure codes. Medical services provided before October 1, 2015 must continue to be billed with ICD-9 diagnosis and procedure codes. Health care providers should follow CMS’s guidelines for billing claims that overlap the ICD-10 implementation date.

For more information about the transition, please visit the CMS website at https://www.cms.gov/Medicare/Coding/ICD10/Index.html.

Medical Fee Schedule Changes, Effective July 1, 2015

Please click here for a notice regarding the changes to the Workers’ Compensation Medical Fee Schedule that are effective July 1, 2015. The notice links to Frequently Asked Questions that provide information and guidance regarding the changes to the Medical Fee Schedule.

Medical Fee Schedule Changes, Effective April 1, 2015

Please click here for a notice regarding changes to the Workers' Compensation Medical Fee Schedule, effective April 1, 2015. The notice links to Frequently Asked Questions that provide information and guidance regarding the changes to the Medical Fee Schedule.

2014 CPT Codes Added to and Deleted from the NCIC Medical Fee Schedule

Pursuant to N.C. Gen. Stat. §97-26(a), the Industrial Commission has added new fees to the Medical Fee Schedule for 2014 current procedural terminology (CPT) codes released by the American Medical Association. The Industrial Commission also has deleted certain CPT codes. These changes are effective for January 1, 2014. Click here for the lists of added and deleted codes.

Announcement Regarding Electronic Medical Billing and Payment

Pursuant to N.C. Gen. Stat. §97-26(g1), the Industrial Commission was directed to adopt rules requiring electronic medical billing and payment processes. The Industrial Commission subsequently adopted Electronic Billing Rules 101-109 in 2012. These rules were then held in abeyance in conjunction with other rule making efforts and to allow the Commission to develop an implementation guide. The Electronic Billing and Payment Companion Guide is now in final form and ready for publication. Click here for access to the guide. This guide can also be accessed on the Commission’s webpages for Carriers and for Medical Providers.

The date for implementation of electronic medical billing in the adopted rules referenced above is March 1, 2014. The Commission received and considered feedback and multiple requests for extensions of the March 1, 2014 deadline from employers, carriers, third-party administrators, and medical billing companies. In order to allow these stakeholders additional time for preparation, the Commission will not require compliance with the Electronic Billing Rules until July 1, 2014, with regard to electronic medical billing processes. The rules and portions of the companion guide that govern and require electronic medical payment processes will not be mandatory until January 1, 2015. No additional extensions will be granted.

Update Regarding Medical Fee Schedule

On January 1, 2013, the Industrial Commission enacted 04 NCAC 10J .0101 Fees for Medical Compensation. This new rule revised the payment structure for medical treatment under the Commission’s Medical Fee Schedule and Hospital Fee Schedule. These adjustments were made on staggered dates: (1) January 1, 2013; (2) February 1, 2013; and (3) April 1, 2013. The Industrial Commission has provided three notices regarding these changes and encourages all insurance carriers, self-insured groups and administrators, and managed care organizations to make timely and accurate payment for medical services in accordance with the rule and guidance provided in the following notices:

• January 16, 2013 announcement for January 1, 2013 changes: /011613notice.pdf
• January 30, 2013 announcement for February 1, 2013 changes: /013013notice.pdf
• March 22, 2013 announcement for April 1, 2013 changes: /ncic/pages/032213notice.pdf

2013 CPT Codes Added/Deleted to the NCIC Medical Fee Schedule

Pursuant to N.C. Gen. Stat. §97-26(a), the Industrial Commission has added new fees to the Medical Fee Schedule for 2013 current procedural terminology (CPT) codes released by the American Medical Association. The Industrial Commission also has deleted certain CPT codes. These changes are effective for January 1, 2013. Click here for the updated list.
 

Updated Medical Fee Schedule, Effective January 1, 2013

Pursuant to 04 NCAC 10J .0101, see this notice regarding recent revisions to the Fees for Medical Compensation.

NCIC's Medical Provider Fee Dispute Resolution Procedure

Pursuant to N.C. Gen. Stat. §97-26(i), the N.C. Industrial Commission adopted the Medical Provider Fee Dispute Resolution Procedure.

Revised Forms and Procedures

On April 1, 2008, all Employer/Carrier/Administrators received the following notice in the Form 18 Acknowledgment letter: “ATTENTION EMPLOYER/CARRIER/ADMINISTRATOR: Within 30 days after receipt of the Form 18, you must file a Form 21, 60, 61, or 63 to admit, deny or pay without prejudice. The failure to comply with this requirement will subject you to sanctions.” During the implementation period of April 1, 2008 through July 31, 2008, no sanctions were imposed.

In compliance with N.C. Gen. Stat. §97-78, the Industrial Commission adopted Forms 18, 19, 25R, 26, 26A, 60, and 63 (all revised 8/6/08) through Minutes. Please click here for a summary of instructions regarding related policies and procedures and here for complete instructions.

Rating Guide

This section is made available to the physicians of the State of North Carolina as a guide in rating industrial accidents. It has been felt that a reference point was needed by physicians in making impairment evaluations. This section is intended to be used only as a guide and basic outline for physicians making rating examinations of individuals who have had industrial injuries to their spine or extremities. Please Click Here to see the Rating Guide.

Medical Status Questionnaire

This questionnaire, which has been approved by the North Carolina Industrial Commission, may be submitted by an employer/insurer paying compensation for an admitted workers’ compensation claim to medical providers who have treated an employee for a work-related injury or condition.Please Click Here for the Questionnaire.

Medical & Rehabiltiation Forms