Updates to the NCIC Medical Fee Schedule

In Accordance with the N.C. Industrial Commission’s
1996 Medical Fee Schedule and Subsequent Updates

Jennifer Gudac
Chief Medical Fee Examiner
N.C. Industrial Commission
E-mail: gudaca@ind.commerce.state.nc.us

Table of Contents

NOTE: These items were last updated May 1, 2000.

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`N.C. Industrial Commission · Medical Billing Section · 4337 Mail Service Center · Raleigh, NC 27699-4337
Telephone:  (919) 733-5055 · Fax:  (919) 715-0282
Internet Address:  http://www.comp.state.nc.us/

When entering CPT codes in the 70000 series (X-rays), you must also enter a modifier. For both technical and professional component, bill radiology code plus modifier B. Use modifier "27" if billing for the technical component only. Use modifier "26" for if billing for the professional component only.

Technical (taking) "27"

Professional (reading) "26"

Both technical and professional "B"

CPT Code 76140— Charge for a "Consultation on X-ray examination made elsewhere" is not allowed in conjunction with an office visit charge. CPT Code 76140 is included in the office visit charge. If submitted separately with no office visit charge, you may allow a charge for CPT Code 76140.

The following procedures have been added to the North Carolina Industrial Commission Medical Fee Schedule and are identified by the American Medical Association’s Current Procedural Terminology (CPT).

ABBREVIATIONS: BR = by report; PC (26) = professional component; and TC (27) = technical component.

Pathology and Laboratory Section 7

Pathology and laboratory CPT codes 80002 through 89399 may require a modifier. (See Medical Fee Schedule and this update for codes that require modifiers).

The following procedures have been added to the North Carolina Industrial Commission Medical Fee Schedule and are identified by the American Medical Association’s Current Procedural Terminology (CPT).

ABBREVIATIONS: BR = by report; PC (26) = professional component; and TC (27) = technical component.

CPT Codes 95900, 95903, 95904, and 95937 require the number of nerves in the time field. These should be listed on Form 25M or the Form 1500. There is a taking and reading fee for each of these codes in the new Medical Fee Schedule and modifiers are required.

Special Services CPT codes will require modifiers.

The North Carolina Industrial Commission has reviewed processing procedures of diagnostic testing when physicians perform both the technical and professional components at a hospital facility. In accordance with the North Carolina State Health Plan, whom by law the Industrial Commission is to emulate, the North Carolina Industrial Commission is issuing the following rules to apply in cases when the physician or radiologist performs the interpretation (professional) and the diagnostic services (technical) within the hospital facility.

If taking and reading, you will be allowed for both, using modifier B. (Modifier WJ will be acceptable.)

Hospital may charge for use of equipment.

No allowance for hospital visit, unless medically necessary for physician to treat patient.

The Industrial Commission asked Medicode to research CPT Codes 90700-90799. Because of the variance of cost for the different injections, the providers are not receiving reimbursement to cover their cost. We are implementing a policy to allow flexibility in payment when the injection materials have a significant cost over and above the value of the procedure. The invoice may be attached to the bill to verify the cost. If invoice is not submitted, the Carrier has the right to request a copy if they feel it necessary. We allow a 20 percent (20%) markup above the cost.

When an injection is given during an office visit service provided by a physician, the cost of providing the injection is included in the payment for the office visit. The cost of the injectable medication may be billed using CPT code 99070 or the CPT code(s) assigned in the North Carolina workers’ Compensation Fee Schedule, which is for materials. When the injection is provided without services by the physician, you may use CPT code 99211 and charge for the medication using code 99070 or CPT codes assigned in the Fee Schedule which is for the materials.

The North Carolina Industrial Commission wishes to address changes in fees for two CPT Codes. Based on recommendation from the North Carolina Industrial Commission Medical Advisory Committee and a decision from the North Carolina Industrial Commission, the reimbursement rates for biofeedback will be changed.

Code Allowance (Previous Allowance)

CPT Code 90901 - $78.00 ($22.00)

CPT Code 90911 - $124.00 ($176.11)

Providers may continue to use the older biofeedback codes, as long as the 1996 Fee Schedule is in effect.

Please note amendment in the following fees for technical and professional components. Previously, the fee schedule did not separate the maximum allowable into technical and professional components. These fees are in accordance with current fee schedule based on 1998 values.

The following procedures have been added to the North Carolina Industrial Commission Medical Fee Schedule and are identified by the American Medical Association’s Current Procedural Terminology (CPT).

ABBREVIATIONS: BR = by report; NA = No allowance; PC (26) = professional component; TC (27) = technical component; ** procedure performed in a facility setting.

These codes range from 90801 through 90899. None of these codes require time with the exception of 90830. For this code please enter a (1) for 0 to 60 minutes and a (2) for two hours et cetera.

There are no codes assigned in the CPT book. The Industrial Commission has its own codes:

PSY01 Consultation no time $119.00 allowance

PSY02 Return visit time required $75.00 per hour allowance

PSY03 Testing time required $75.00 per hour allowance

PSY04 Group time required $20.00 per hour allowance

Hypnotherapy—Psychologists are authorized to use CPT Code 90880—the Commission will allow this code for the amount listed in the N.C. Medical Fee Schedule.

Psychologists may utilize the CPT codes for biofeedback procedures.

The North Carolina Industrial Commission wishes to address changes in fees for two CPT Codes. Based on recommendation from the North Carolina Industrial Commission Medical Advisory Committee and a decision from the North Carolina Industrial Commission, the reimbursement rates for biofeedback will be changed.

Code Allowance (Previous Allowance)

CPT Code 90901 - $78.00 ($22.00)

CPT Code 90911 - $124.00 ($176.11)

 

CPT Code 99075 "Medical Testimony" is a fee set by the NCIC hearing officer. Pay per the hearing officer’s "Opinion and Award."

The Commission has ruled unofficially that travel to secure job replacement is a part of Rehabilitation services and covered under G.S. §97-25 when properly documented. Effective March 15, 1995, travel expense increased to 25 cents a mile.

Job-site visits, reviewing video tapes, and viewing X-rays are covered under Rehabilitation services but need prior approval from the Insurance Carrier. These bills are not submitted to the Commission, but are paid by the Carrier.

Reimbursement for supplies and equipment must not exceed twenty (20) percent above the provider’s cost. An invoice may be required by the carrier before reimbursement is made.

There are some items that have no CPT codes, such as any type of supply or minor anesthesia. These must be entered as 99070.

Transcutaneous Electrical Nerve Stimulation (TENS) units, neuromuscular units, and continuous passive units are billed using the Industrial Commission assigned codes. The codes are listed in the Physical Medicine Section of the N.C. Medical Fee Schedule. Rental Codes are for daily, weekly, and monthly use.

The CPT Code BT100, which the Commission used in the past for back testing, has been eliminated; and you should advise the Providers to use CPT Code 97750 and this code requires time. We have received inquiries regarding approvals of CPT Code 97750 for Physical Therapy. CPT Code 97750 is used to represent physical performance testing or measurements in units of 15 minutes. More than one unit may be allowed for this code. 97750 replaced former codes 97720, 97721, and 97752. These codes were replaced per the 1995 edition of Current Procedural Terminology. The N.C. Industrial Commission Medical Fee Schedule, Physical Medicine Section F, states that 97720, 97721, and 97752 are to be used only once for the same body area within a 30-day period. The same applies for code 97750. However, there may be a reason testing has to be done twice in 30-day period (e.g., when such testing was ordered by the treating physician). When billing for Functional Capacity, the Medical Provider must use the Code EV100 and this is to be paid per agreement. These bills are not to be sent to the Industrial Commission for calculation, because they are to be paid per agreement.

For physical therapy, you must enter a time in total minutes for most CPT codes. The provider must be a licensed physical therapist or occupational therapist. Codes 97010 through 97028 will not require the time to be entered and only one of each of the above codes will be allowed per day. You can allow more than one of these codes per visit, but not the same code more than once during the same visit. OHT01 has been eliminated and occupational therapists must use physical therapist codes. (See new 1996 Medical Fee Schedule for changes in time). Billing an extra fee for electrodes is allowed for iontophoresis code 97033 only.

SMT01—Sport Therapy—approved in full.

YM100—Y membership—approved in full.

The following principles apply to workers' compensation and chiropractic care:

1. Chiropractic care IS covered under the Workers' Compensation Law in North Carolina and it would be false and misleading for an insurance company or its representatives to state or imply otherwise. N.C.G.S.§ 97-2(20) and § 97-88.2

2. Pursuant to Rule 802 of the Workers Compensation Rules of the North Carolina Industrial Commission, any employer, carrier or third party administrator who routinely denies chiropractic treatment as a matter of policy may be subject to sanctions by the Industrial Commission.

3.When an injured employee has reported the injury to his or her employer and the employer has not made a direct referral to a physician, the employee may go to the physician of his or her choice. N.C.G.S. § 97-25

4. When a chiropractic physician is the initial treating physician, either through direct employer referral or under circumstances described in Paragraph 3 above, an authorization-to-treat slip is NOT required.

5. A chiropractic physician may treat an injured worker for up to 20 visits without further authorization.

6. When more than 20 visits are necessary, the chiropractic physician must obtain authorization for additional visits from the payor, i.e., the self-insured employer, the insurance company or the third party administrator.

7. When an injured employee has been treated by a physician and wishes to be treated by a different physician, who may or may not be a chiropractic physician, he or she has the right to request treatment by a physician (chiropractic or otherwise) of his or her choice and should contact the employer or write to the Industrial Commission to obtain permission. N.C.G.S. § 97-25

8. An employer can request that an injured employee seek evaluation by another physician, but the injured employee may continue treatment with the chiropractic physician for up to the initial 20 visits. N.C. G.S. § 97-27

9. An employer, insurance company, or third party administrator may not unilaterally terminate a patient's chiropractic treatment during the initial 20 visits.

10. Except for the number of visits for the initial 20 visits, visits to a chiropractic physician are subject to Utilization Review.

GUIDELINES

Chiropractic medicine may be an integral part of the healing process for some injured workers. This schedule includes codes for chiropractic medicine, i.e., those modalities, procedures, tests, and measurements in the chiropractic medicine section, representing specific therapeutic procedures performed by licensed chiropractors and within their scope of practice, or by support personnel under direct supervision of a licensed chiropractor. Chiropractic physicians must meet the following requirements in order to be paid under this fee schedule:

A. CHIROPRACTIC MEDICAL ASSESSMENT

1. An assessment, including a plan of care, must be performed to determine if a patient will benefit from chiropractic treatment.

2. When billing for the assessment, plan of care, and visit, the chiropractor shall use only one of the appropriate CPT Evaluation and Management codes.

B. QUALIFICATIONS FOR REIMBURSEMENT

1. The patient's condition must have the potential for restoration of function.

2. The treatment must be specific to the injury and have the potential to improve the patient's condition.

C. PLAN OF CARE

1. An initial plan of care must be developed and filed with the payor. The content of the plan of care, at a minimum, should contain:

a. The potential degree of restoration and measurable goals (i.e., potential restoration is good, poor, low, guarded)

b. The specific treatments to be provided, including the frequency and duration, in units, of each treatment

c. The estimated duration of the treatment regimen

2. Preparation of the initial plan of care is included in the initial assessment, plan of care and visit, and no additional fee shall be charged for it.

3. If treatment beyond the initial 20 visits is authorized, the plan of care must be updated at the end of the initial 20 visits and at least every 30 days thereafter. The updated plan must be signed by the chiropractic physician and submitted to the payor. Charges for this reassessment and updated plan of care shall be billed using the appropriate CPT Evaluation and Management code.

D. REIMBURSEMENT

1. Visits for treatment may not exceed one visit per day without prior approval from the payor.

2. A minimum of an initial visit and 19 subsequent visits is allowed upon initial authorization of chiropractic treatment. Treatment exceeding 20 visits must have preauthorization from the payor for continuing care. Treatment must meet the following guidelines:

a. The treatment must tend to effect a cure, give relief, or lessen the period of disability.

b. When approval to treat is given by telephone, documentation should be made by the provider in the patient's medical record indicating the date and name of the payor representative giving authorization for the treatment.

Physical Medicine Modalities are now divided into two groups: "supervised" and "constant attendance." Supervised modalities will be reimbursed as billed for

only one unit per visit. Constant attendance modalities will be reimbursed as billed in units of 15 minutes. Appropriate rounding up or down is expected, using professional judgment. Billing for excessive units will be subject to Utilization Review.

4. A chiropractic physician may charge and be reimbursed for a follow-up examination in the following cases:

a. Reassessment as defined in Section C Item 3 (PLAN OF CARE) above.

b. A definitive change in the patient’s condition occurs.

c. The patient fails to respond to treatment and there is a need to change the treatment plan.

d. The patient has completed the treatment regimen and is ready to receive discharge instructions.

E. TENS UNITS

1. TENS (Transcutaneous Electrical Nerve Stimulation) treatment may be provided either by the chiropractic physician or under his supervision.

2. Authorization, including selection of the vendor, must be obtained from the payor before rental of a TENS unit or before arrangements are made for the purchase of a TENS unit at a price in excess of $250.

F. SUPPLIES and EQUIPMENT

1. Chiropractic physicians must obtain authorization from the payor before purchase or rental of durable medical equipment in excess of $100.

2. Reimbursement for supplies and equipment must not exceed 20 percent above the provider's cost. An invoice may be required by the carrier before reimbursement is made.

3. Reimbursement for vitamins, herbs and nutritional supplements is not allowed under this fee schedule.

G. OTHER INSTRUCTIONS

1. Charges will not be reimbursed for publications, books, or video cassettes unless by prior approval of the payor.

2. All charges for services must be clearly itemized by CPT code. The Federal tax ID number or chiropractor’s social security number must be on the bill. Billing is also subject to all medical billing directives of the Industrial Commission.

Chiropractors may be reimbursed the regular fee schedule allowance for the following laboratory examination: 81002, urinalysis dipstick, $7.76

Chiropractors may use CPT code 99080 for a narrative report reimbursed up to $165.00. This may be billed when the payor has requested more than the usual information furnished in standard reporting forms.

Because each of the programs or evaluations listed below varies in time depending on the injured employee, the Industrial Commission will not set fees. The provider must obtain authorization from the Employer/Self-Insurers or Insurance Company before entering a patient into a program. If they are in agreement with the program, the Self-Insurer or the Insurance Company may pay the bill and retain all bills and reports in their file. The Commission requests that you deal directly with the Employer/Self-Insurer or Insurance Company for payment. Once you have permission to enter a patient in a work conditioning or work hardening program, all charges from Day One until the patient has been released are all inclusive charges. This includes physical therapy, psychiatric, psychological, neuropsychologist, and other treatment. When billing for these services, the Medical Provider must use the codes listed below:

1. Work Conditioning WC100

2. Work Hardening WH100

3. Evaluations EV100

4. Rehabilitation with Psychological Services PSY00

These services are covered under the agreement between the Self-Insurer/Insurance Company and the Medical Provider. Each of these programs or evaluations listed above varies in time. Pay per your agreement. Do not submit the above bills to the Industrial Commission.

The Industrial Commission has given the Self-Insurers and Insurance Companies permission to pay the following bills without submitting them to the Industrial Commission for approval. Please obtain a copy of the bill for your file. The North Carolina Industrial Commission does not process the following bills.

1. Travel Bills—$.25 per mile. Patients must travel at least 10 miles one way in order to collect. Travel for job replacement is also covered. Effective March 15, 1995, the travel expense rate increased to $.25 cents a mile.

2. Drug Bills—Pay in full.

3. Ambulance—Pay in full.

4. Out-of-State Bills—Pay in full.

5. Minor Medical ($2,000 or less)—Consult the Medical Fee Schedule. To save time and the submission of a Form 19, if there is a "BY REPORT" item on the bill, you may pay this item in full if the item does not exceed $50.

6. Nursing Bills—Pay in full.

7. Nursing Homes—Pay in full per your agreement.

8. Pain Clinic (Revenue code 511 key only code and total amount)

9. Industrial Rehabilitation—"Work Hardening programs" and "Psychological services"

10. Rehabilitation Nurse Bill—New rule effective January 1, 1993/ Charges must be reflected on Form 51.

 

TOPICAL FLUORIDE TREATMENT (OFFICE PROCEDURE)

SPACE MAINTENANCE (PASSIVE APPLIANCES)

AMALGAM RESTORATIONS (INCLUDING POLISHING)

SURGICAL SERVICES (INCLUDING USUAL POSTOPERATIVE SERVICES)

COMPLETE DENTURES (INCLUDING ROUTINE POST DELIVERY CARE)

PARTIAL DENTURES (INCLUDING ROUTINE POSTDELIVERY CARE)