Bernadine Singh
Chief Medical Fee Examiner
N.C. Industrial Commission
E-mail: Bernadine.Singh@ic.nc.gov
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NOTE 1: To purchase a complete copy of the American Medical Association’s Current Procedural Technology Codes, telephone Ingenix, Inc. at (800) INGENIX (464-3649), option 1, or go to http://www.shopingenix.com/modules/catalog/catalog_category.asp to order a CPT® code book online. NOTE 2: Please report any problems or errors directly to Bernadine.Singh@ic.nc.gov. NOTE 3: This page was last revised on July 30, 2009. |
|
Introduction |
CPT
Codes and Fees /
Commission Assigned Codes |
| Evaluation and Management Section 3 | Physical Medicine Section 10 |
| Anesthesia Section 4 (effective April 1, 2000) | Chiropractic Fee Schedule Section 11 (effective March 1, 2001) |
| Surgery Section 5 | Industrial Rehabilitation Section 12 (effective January 1996) |
| Radiology Section 6 | Dental Fee Schedule Section 13 (effective May 1, 2007) |
| Pathology and Laboratory Section 7 | Hospital and Ambulatory Surgical Center Section 14 (effective July 15, 2002) |
| Medicine Section 8 | Forms Section 16 (effective February 1, 2000) |
| Special Services Section 9 | Durable Medical Equipment/Supply Fee Schedule (effective January 1, 2008) |
Proper Reimbursement of Medical Bills
Beginning July 27, 2009, for service dates on and after that date, the following inpatient hospital billing band and outpatient and ambulatory surgical center reimbursement rates shall come into effect:
Former Chairman Buck Lattimore's July 12, 2005 memo states:
It has come to the attention of the Industrial Commission that certain insurance carriers, self-insurers, and third-party administrators are requesting invoices for inpatient hospital bills. G.S. §97-26 states the Commission may consider any and all reimbursement methodologies including, but not limited to, the use of current procedural terminology (“CPT”) codes and diagnostic-related groupings (“DRGs”). In utilizing the DRG methodology for reimbursement, providers are entitled to 77.07% to 100% of billed charges. No additional reductions shall be taken for supplies or equipment as the Durable Medical Equipment Supply Fee Schedule applies only to items billed on a CMS (HCFA) 1500 not UB-92. However, per Rule 407, when a responsible party seeks an audit of hospital charges, and has paid the hospital charges in full, the payee hospital, upon request, shall provide all reasonable access and copies of appropriate (medical) records (not invoices) without charge or fee, to the person(s) chosen by the payor to review and audit the records. In conclusion and adherence to G.S. §97-26, all inpatient medical bills are subject to DRG reimbursement methodology with no additional reductions being allowed. All outpatient medical bills must be paid at 95% of billed charges with no additional reductions being allowed. Medical services being performed at ambulatory surgical centers (ASCs) are to be paid at 100% of billed charges. Medical services billed on a CMS (HCFA) 1500 are reduced according to the fee established in the Medical Fee Schedule for the current procedural terminology (“CPT”) codes and the Health Care Procedure Coding System (HCPCS) codes. If a Health Care Procedure Coding System (HCPCS) code is billed on the CMS (HCFA) 1500, and does not have a fee assigned in the Medical Fee Schedule, the provider is entitled to 20% above invoice cost for the Health Care Procedure Coding System (HCPCS) code only.
Please see former Chief Medical Fee Examiner Jennifer Gudac's June 26, 2002 memo on Hospital Billing Procedures and Proper Reimbursement.
Effective November 1, 1995, payers applying the
Commission’s Medical Fee Schedules for physicians and other non-hospital
providers pursuant to the Commission’s permission and parameters dated
January 19, 1995 (effective February 15, 1995), are hereby granted permission
to pay charges for OUTPATIENT hospital services without prior submission of
the providers’ bills to the Commission for analysis. Hospital OUTPATIENT
facility fees and outpatient ancillary charges shall be paid at 5% less than
charges billed, when billed at the amounts provided (before any discounts)
under the Blue Cross and Blue Shield of North Carolina Contracting Hospital
Agreement and the State of North Carolina Teacher’s State Employee’s
Comprehensive Medical Plan (SEHP) Hospital Reimbursement Contract with the
provider currently in effect, which we understand to be the rates presently
charged by all North Carolina Hospitals as their “normal” charges.
Compensation payers will pay as provided by N.C.G.S. § 97-26 (b). This
permission to process outpatient hospital bills is subject to being approved
as a medical bill processor by the North Carolina Industrial Commission.
At this time, all inpatient hospital bills (not nursing home bills) must be submitted
to the Commission for processing unless the provider has agreed to accept a
different amount or reimbursement methodology.
It is anticipated that, in the future, payers willing
to duplicate the DRG grouping and pricing capability of the Commission’
Medical Section will be allowed to handle inpatient hospital bills as well.
Your comments on this, whether you desire to do this, preparation time
necessary to prepare for the testing, workable arrangement for submitting
random data samples for audit, etc., will be appreciated.
Hospitals
It is the duty of the hospital through its admitting
office to attempt to determine whether an injury case is to be handled under
workers’ compensation. If an inquiry made at the time of admission indicates
the person was injured on the job, it is likely that it will be a workers’
compensation case.
When the patient’s condition becomes such that
further inpatient care becomes only a matter of personal convenience, the
executive officer of the hospital should notify the Commission at once.
No bill will be approved unless it contains a brief
history of the case sufficient to show the nature of the injury and the
treatment rendered.
The Commission will not approve charges for blood
used in transfusions if the patient obtains replacement. An explanatory
statement by the hospital must appear on the face of the bill.
Patients will be approved for ward or semi-private
services only, except (1) when the condition of the patient requires other
accommodations and the attending physician or surgeon so recommends in
writing; (2) where the request for other accommodations is made by the
employer in writing’ or (3) where semi-private or ward service is not
available, private service will be approved. NO bill for other than
semi-private or ward service will be approved unless it bears a statement
identifying the source of authorization for such accommodations. If the
patient for personal reasons alone desires a private room and the patient and
the hospital agree, the hospital may collect the difference between its
regular semi-private and regular private service directly from the patient.
Hospital are to bill at the amounts provided under
the Blue Cross and Blue Shield of North Carolina Contracting Hospital Agreement
and the State of North Carolina Teacher’s State Employee’s Comprehensive
Medical Plan Hospital Reimbursement Contract.
Reimbursement Rates for Various Claims
Explanation of Inpatient Service Reimbursement
Beginning July 1, 1995 the Industrial Commission
began approving inpatient hospital services according to the DRG fee schedule
duplicating State Health Plan contract amounts.
Shortly after the institution of the DRG methodology
by the Industrial Commission, a legislative change was made allowing the
Commission to deviate slightly from the reimbursement system provided by State
Health Plan. The change involved the imposing of end caps for inpatient
allowances when DRG allowances fall below charges or when DRG allowances exceed
charges. The legislative document that explains this provision is Senate Bill
914. This document also explains how the end caps are calculated on an annual
basis.
The following will explain just how the end caps work
when approving inpatient bills for Workers’ Compensation claims.
For services rendered during the period beginning
April 1, 1996 and ending December 31, 1997 the low cap is 90% and the high cap
is 100%. In other words if a calculated DRG allowance falls below 90% of the
hospital’s charges then the reimbursement allowance will be 90% of the charges
and not the DRG. If the DRG allowance exceeds the hospital charges, the
reimbursement allowance will be 100% of the charges and no more. The only time
the DRG allowance will be used for reimbursement is if and when it falls between
the 90% and 100% mark.
For services rendered during the period January 1,
1998 through August 31, 1998, the end caps are 90.67% and 100%. Apply these
percentages in the same manner as the preceding paragraph.
For services rendered during the period September 2,
1999 through January 11, 2000, the end caps are 81.35% and 100%. The 81.35%
floor allowance has been imposed in accordance with Industrial Commission
rule-making procedures and after a public hearing was conducted on July 22,
1999.
For services rendered during the period January 12,
2000 through December 31, 2000, the end caps are 82.28% and 100%. The 82.28%
floor allowance has been imposed in accordance with Industrial Commission
rule-making procedures and after a public hearing that was conducted on December
17, 1999.
For
services rendered during the period January 1, 2001 through December 31, 2001,
the end caps are 77.07% and 100%. The 77.07% floor allowance has been imposed in
accordance with Industrial Commission rule-making procedures and after a public
hearing that was conducted on December 19, 2000.
A revision in N.C.G.S. § 97-26, froze the corridors
of 77.07% and 100% until June 30, 2001. The Commission held a public hearing in
April. Based on the April public hearing, the Commission adopted to continue the
same reimbursement methodology with continuation of the end caps at 77.07% and
100%. These percentages officially became effective July 15, 2002 and will
continue through the year 2002 and thereafter until the Commission commits to a
new reimbursement methodology.
State Health Plan Contract Conditions That Are
Emulated by the N.C. Industrial Commission
The State Health Plan contract includes a list of
inpatient services that will not be reimbursed based on DRG allowances. The
list includes rehabilitative care and psychiatric care. These services will be
reimbursed at the rate of 5% off room and board and 8% off the ancillary
charges.
The State Health Plan contract states that hospitals
will not be reimbursed for interim bills.
In accordance with State Health Plan there are some
revenue codes that are non-covered as well as another group of revenue codes
that should not be billed on the UB-92. This latter group includes
professional fees that should be billed using CPT codes on a CMS (HCFA) form
1500. A copy of this list is enclosed.
Unrelated, Duplicated or Non-supported Charges
Inpatient bill charges that appear unrelated to the workers’ compensation injury, charges that appear to be duplicated in error, or potentially erroneous charges that cannot be supported by documentation are all situations that should be handled directly between the payor and the hospital before submitting the UB-92 to the Commission for calculation. If the parties are unable to resolve the discrepancy, the UB-92 is to be submitted to the Commission for authorized approval. Once the payor issues payment authorized by the Commission, the payor may then audit the hospital records without the hospital charging for said records. See North Carolina Industrial Commission Rule 407.
Protocol for Submission of Hospital Claims
To expedite hospital claims payment; it is always good protocol to submit medical records and itemized statements along with the UB-92 form. According to Industrial Commission rules, the payor is entitled to one free copy of the medical records. Any information submitted with the bill to substantiate the claim as workers’ compensation and to verify services rendered can only enhance the payment process.
Late PenaltyNorth Carolina General Statute 97-18 (i) reads: “If
any bill for service rendered under G.S. 97-25 by any provider of health care
is not paid within 60 days after it has been approved by the Commission and
returned to the responsible party, or within 60 days after it was properly
submitted in accordance with the provisions of this Article, to an insurer or
managed care organization responsible for direct reimbursement pursuant to G.S.
97-26 (g), there shall be added to such unpaid bill an amount equal to ten per
centum (10%) thereof, which shall be paid at the same time as but in addition
to, such medical bills, unless such late payment is excused by the Commission.
Inpatient and outpatient hospital bills for all
Veterans Hospitals, Military Hospitals, and Cherokee Hospital are to be
approved in full per the NCIC Rules. These hospitals bill their physicians’
charges on Form UB92, which also must be approved in full.
Ambulatory Surgery
When processing hospital bills for outpatient
surgery, if a revenue code of 490 (ambulatory surgery) appears on the UB-92,
key bill in under revenue code 490, which will approve entire bill in full.
Ambulatory
surgery services performed at a licensed Ambulatory Surgical Center should be
coded as 490FF, and approved in full.
Emergency Physician Charges
Professional services such as emergency room
physician charges should be billed using the HCFA 1500 Form and processed
according to the fee assigned to the CPT code(s) used.
CRNA Professional Charges
*According to the North Carolina UB-92 Manual, the revenue code 964 is the appropriate code for CRNA professional charges. Revenue code 370 is not appropriate for these professional charges. The Commission’s procedures identify 964 as one of the revenue codes that should be billed on the HCFA 1500. Therefore, hospitals should bill CRNA professional charges on a HCFA 1500 making these charges subject to Fee Schedule rates.
| TABLE 1: Non-covered UB-92 Revenue Codes According to North Carolina State Employees Health Plan. |
UB-92 Revenue Codes |
Health Service Codes |
Description |
18x |
HA149 |
Other—Not Covered Leave of Absence |
221 |
HA149 |
Other—Not Covered Special Charges |
222 |
HA149 |
Other—Not Covered Special Charges |
223 |
HA149 |
Other—Not Covered Special Charges |
229 |
HA149 |
Other—Not Covered Special Charges |
512 |
HA149 |
Other—Not Covered Clinic |
53X |
HA149 |
Other—Not Covered Osteopathic Service |
56X |
HA149 |
Other—Not Covered Medical Social Services |
990 |
HA 149 |
Other—Not Covered Patient Convenience Items |
991 |
HA149 |
Other—Not Covered Patient Convenience Items |
992 |
HA 149 |
Other—Not Covered Patient Convenience Items |
993 |
HA149 |
Other—Not Covered Patient Convenience items |
994 |
HA149 |
Other—Not Covered Patient Convenience items |
995 |
HA149 |
Other—Not Covered Patient Convenience items |
996 |
HA149 |
Other—Not Covered Patient Convenience items |
998 |
HA149 |
Other—Not Covered Patient Convenience items |
999 |
HA149 |
Other—Not Covered Patient Convenience items |
Please note the enclosed information regarding North Carolina Workers’ Compensation and reimbursement of hospital claims. This article has been updated to clarify the issue of non-covered revenue codes. The previous article contained an excerpt from the State Health Plan, which has led to confusion in denying all codes from 900-989. Not every code in the 900 group is considered non-covered. Please review the list for specific codes that would fall into non-covered category, and those that should be billed on a professional bill.
| TABLE 2: The following revenue codes are professional fees and should not be billed on the UB-92. If billed on the UB-92 the charge will be denied as non-covered. The provider may bill for these services on a HCFA 1500. |
UB-92 Revenue Codes |
Health Service Codes |
Description |
900 |
HA149 |
Other—Not Covered Psychiatric/Psychological Services |
902 |
HA149 |
Other—Not Covered Psychiatric/Psychological Services |
903 |
HA149 |
Other—Not Covered Psychiatric/Psychological Services |
909 |
HA149 |
Other—Not Covered Psychiatric/Psychological Services |
910 |
HA149 |
Other—Not Covered Psychiatric/Psychological Services |
911 |
HA149 |
Other—Not Covered Psychiatric/Psychological Services |
914 |
HA149 |
Other—Not Covered Psychiatric/Psychological Services |
915 |
HA149 |
Other—Not Covered Psychiatric/Psychological Services |
916 |
HA149 |
Other—Not Covered Psychiatric/Psychological Services |
919 |
HA149 |
Other—Not Covered Psychiatric/Psychological Services |
940 |
HA149 |
Other—Not Covered Other Therapeutic Services |
941 |
HA149 |
Other—Not Covered Other Therapeutic Services |
96X |
HA149 |
Other—Not Covered Professional Fees |
97X |
HA149 |
Other—Not Covered Professional Fees |
981 |
HA149 |
In-state Provider Professional Fees |
982 |
HA149 |
Other—Not Covered Professional Fees |
983 |
HA149 |
Other—Not Covered Professional Fees |
984 |
HA149 |
Other—Not Covered Professional Fees |
985 |
HA 149 |
Other—Not Covered Professional Fees |
986 |
HA149 |
Other—Not Covered Professional Fees |
987 |
HA149 |
Other—Not Covered Professional Fees |
988 |
HA149 |
Other—Not Covered Professional Fees |
989 |
HA149 |
Other—Not Covered Professional Fees |
Other Services
Special Duty Nursing
When deemed urgent and necessary by the attending
physician, special duty nurses may be employed. Such necessity must be stated in
writing when more than seven days of nursing services are required.
Board charges for the special nurses are included in
the allowed fees.
Except in unusual cases where the treating physician
certifies it is required, fees for practical nursing services by members of the
immediate family of the injured will not be approved unless written authority
for the rendition of such services for pay is first obtained form the Industrial
Commission. In cases where such written authorization is given, the Industrial
Commission will establish a fee commensurate with the services rendered.
Registered Nurses and Licensed Practical Nurses
The usual fee charged by nurses will ordinarily be
approved by the commission. One nurse attending two or more patients will be
limited to one and one-half the regular fee.
X-Ray
Examination
All x-ray examinations must be justified by sound
medical indications. Routine admission chest films in the hospital will be
approved if the taking of such films is a requirement of the particular hospital
submitting such a bill. No approval for such studies as GE series, barium enema,
gallbladder series, etc., will be made unless such examinations are deemed
essential to a differential diagnosis by the attending physician and so stated.
Upon request, films should be submitted to the
Medical Department of the Commission for review by the Medical Advisory
Committee.
Home
Health Care Agency
Home health care agencies must bill on the UB-04 for Workers’ Compensation Cases-Reports, codes and breakdowns of charges must be submitted with bill to the Employer/Self-Insurers or Insurance Company.