NORTH CAROLINA INDUSTRIAL COMMISSION

Help Line: (800) 688-8349, (919) 716-1700, or infospec@ic.nc.gov
Fraud and Insurance Compliance Hotline: (888) 891-4895 or fraudcomplaints@ic.nc.gov

For Medical Providers

Information for Medical Providers

Permanent Rule Amendment to Medical Fee Schedule, Effective June 1, 2018

On October 19, 2017, the Rules Review Commission approved the rule amendment to Rule 04 NCAC 10J .0103 (recently recodified as 11 NCAC 23J .0103). Please click here to view an annotated version of the approved rule showing all amendments. However, the rule received ten or more letters of objection. Therefore, this rule was subjected to legislative review with a delayed effective date of the earliest of the 31st legislative day of the General Assembly's session or the date of adjournment.

Upon receiving additional clarification regarding the count of legislative days from the Senate Principal Clerk’s Office and the House Principal Clerk’s Office, it was determined the legislature reached its 31st day of this regular session on June 1, 2018. This clarification affected the rules of several agencies, including Rule 11 NCAC 23J .0103.

For dates of service between April 1, 2015 to May 31, 2018, the effective rule can be found here. For dates of service on or after June 1, 2018, the effective rule can be found here.
 

Important News Regarding Ambulatory Surgery Center Fee Schedule Rule [UPDATED]

On November 21, 2017, by a unanimous decision, the Court of Appeals issued an Opinion reversing the August 9, 2016 Decision of Superior Court Judge Paul Ridgeway and remanding the case for entry of an order affirming the Industrial Commission’s December 14, 2015 Declaratory Ruling. The Court of Appeals held that the ambulatory surgery center provisions of the workers’ compensation medical fee schedule that became effective April 1, 2015 were promulgated in accordance with the Administrative Procedure Act and are valid retroactively and prospectively. Please click here to read that decision.

On April 6, 2018, the North Carolina Supreme Court denied Surgical Care Affiliates’ request for a Petition for Discretionary Review. This leaves in place the November 2017 Court of Appeals decision in favor of the Industrial Commission. Rule 11 NCAC 23J .0103, effective April 1, 2015, continues to be the effective fee schedule for ambulatory surgery centers.

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 Rule 11 NCAC 23J .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:

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 Rule 11 NCAC 23J .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.

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

Form 25C

Authorization for Rehabilitation Professional to Obtain Medical Records of Current Treatment. Please fill out this form completely, sign it and mail it to the rehabilitation professional named on the form.

Referral Form

Medical Rehabilitation Nurses Section Referral Form. Please fill out this form completely, making sure to include the I.C. Number for the claim. Please fax the completed and signed Form 25N to
(919) 508-8350
ATTN: Medical Rehabilitation Nurses
.

The completed form can be mailed to us at:

NC Industrial Commission
1236 Mail Service Center
Raleigh, NC 27699-1236
ATTN: Medical Rehabilitation Nurses

Workers Comp. Medical Status Questionnaire

The Workers Comp. Medical Status Questionnaire 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.

Form 25N

Notice to the Commission of Assignment of Rehabilitation Professional. Please fill out this form completely, making sure to include the I.C. Number for the claim. Please submit to the Commission as directed on the form.

The completed form can be mailed to us at:

NC Industrial Commission
1236 Mail Service Center
Raleigh, NC 27699-1236
ATTN: Medical Rehabilitation Nurses

You can also e-mail your Form 25N in PDF format to 25n@ic.nc.gov.

Form 25R

Evaluation of Permanent Impairment.

A copy of this form must be provided to the employee or the employee's attorney of record, if any. The original should be mailed to us at the Industrial Commission.