Notes for Processing Medical Bills

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

Nick P. Davis
Chief Medical Fee Examiner
N.C. Industrial Commission

On March 1, 1996, the N.C. Industrial Commission (NCIC) started processing medical bills using the new 1996 Medical Fee Schedule. Medical bills will be approved by the 1996 fee schedule regardless of the date of service. Insurance Carriers, Self-Insurers, and Third-Party Administrators processing their own medical bills will be expected to switch over to the new Medical Fee Schedule as soon as possible and also approve all medical bills by the 1996 fee schedule regardless of the date of service. The Commission will be glad to review any medical bills in question.

Please refer to the notes below when processing the following types of medical bills. The Current Procedural Terminology (CPT) codes may be changed only after discussing the proposed change with the Medical Provider and obtaining an agreement that it can be changed. The medical bill analysis shall clearly show that the CPT code was changed and shall state the reason.

Physician’s Bills

1. Enter any modifiers that accompany CPT codes.

2. If an "80", "81", or "82" modifier is used by an assistant surgeon, make sure the modifier is a licensed physician. If physician’s assistant (PA) assists during surgery, replace the CPT code with "MC001" and enter "80" in the modifier, because we do not allow for a PA in surgery. If a PA sees a patient in a physician’s office and the physician signs the bill and is present, the Commission will allow the charge.

3. When entering CPT codes in the 70000 series (X-rays), you must also enter a modifier. If physicians take and read X-rays, use modifier "B"; if they only take X-rays, use modifier "27"; and if they only read X-rays, use modifier "26". Most physicians’ bills are for both taking and reading X-rays. Radiologists’ bills will vary.

4. 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).

SMT01—Sport Therapy—approved in full.
YM100—Y membership—approved in full.

5. When anesthesiologist enter bills, they will always use the CPT code for the surgery; but you must convert this to "ANT01" and enter the time in the unit value. You will only be able to detect this if there is a physician’s name at the bottom of the bill or there is a time listed by the surgery. For Certified Registered Nurse Anesthetists, use code ANT02 and the time and charge.

6. Consult the Medical Fee Schedule for CPT codes that require time in the time/unit field for physical therapy, psychiatric, and psychological codes. All Anesthesia codes require time to be entered in the time/unit field. (See item 5 for billing Anesthesia.)

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

8. CPT Codes 95900 and 95904 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.

9. Transcutaneous Electrical Nerve Stimulation (TENS) units, neuromuscular units, and continuous passive units have no code. The Industrial Commission has assigned codes for these, and they are listed in our Medical Fee Schedule in the physical medicine section. Rental Codes are for daily, weekly, and monthly use.

10. Emergency room physicians use Form 25M or Form 1500. All bills are reduced by our Medical Fee Schedule regardless of the type of hospital. Hospitals should all use CPT codes.

11. Watch for surgeons billing for two surgeries. If both surgeries take place through the same incision, they should code the second surgery with a "51" modifier. If each surgery requires a separate incision, we allow full fee for each.

12. The Industrial Commission does not allow for acupuncture, "no show" visits, telephone calls, and massage therapy. Massage Therapy applies to a Massage Therapist only, not a Physical Therapist, Orthopaedist, or Chiropractor. Usually, a Massage Therapist is not licensed; but if the Massage Therapist is licensed, you would pay per agreement.

13. If surgery is performed, the Medical Fee Schedule states the number of days for which follow-up care is covered. Watch your bills for charges for hospital or office visits only for this period of time. The office visit is the only item they cannot charge for. Materials and medications are allowed. Change the office visit code to MC004 and allow zero amount if follow-up days have not been met.

14. Any starred procedure—i.e., any procedure coded with an asterisk (*)—is for the surgical procedure only. Providers may charge for office visits, surgical procedures, and all follow-up visits.

You have to evaluate each bill and make a decision whether an office visit is allowed. Our Fee Schedule in the Surgery and Explanation of Fee Schedule Sections states:

1. Office visit is not allowed.

2.  

1. Initial office visit may be allowed using CPT 99025 when the starred procedure is carried out at the time of an initial visit and the surgical figure constitutes the major service at that visit.

2. The appropriate office visit is allowed if significant identifiable services other than the starred procedures are performed.

3. Follow-up office visit is not allowed if the starred procedure constitutes the major service.

4. Hospital visit is allowed if the starred procedure requires hospitalization. In other words, if the provider sees patient in his/her office but necessitates hospitalization, the hospital visit is allowed.

15. Ambulatory surgery services by a physician should be coded as 490FF, and approved in full.

16. CPT Code 64450 should only be allowed when done separately. Do not allow with a bill where a surgery code was allowed on the same day. If the surgery has an asterisk beside it, you may allow it.

17. Arthroscopy surgery codes 29870 through 29909 are unbundled. This procedure is a global fee; therefore, only one fee will be allowed unless special consideration warrants otherwise. In such cases, operative notes must be sent for review.

18. No allowance is made for codes 64727 or 61712 (Microsurgery).

19. Code 64830 is allowed as twenty percent (20%) of the surgeon’s bill for repair of nerves only.

20. Modifier "20" is for use of the microscope. We allow twenty percent (20%) for this code on surgery for nerves.

21. Modifier "22" is seldom allowed, and then only if the surgery was complicated. If the surgery was complicated, we allow an additional twenty percent (20%) and the surgery charge.

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

23. Bilateral Procedures—When billing for bilateral procedures use the CPT code for surgery with a modifier "50" and the Commission will allow fifty percent (50%) more for the codes listed below.

24. Pathology and laboratory CPT codes 80002 through 89399 have now been assigned fees. Some of these codes will require a modifier. (See Medical Fee Schedule for codes that require modifiers).

25. Special Services CPT codes 99185, 99186, 99190, 99191, and 99192 will require modifiers.

26. If a Rehabilitation Nurse requests time to spend with a physician to discuss the patient, the Medical Provider may use CPT Code 99241.

27. The Commission has suggested that the Medical Provider use the codes listed below for the following:

CPT Code 99215—Rating
CPT Code 99275—Second Opinion
CPT Code 99080—Narrative Report
IME—Independent Medical Evaluation (See Attached Sheet)

28. 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.

29. Job-site visits and viewing of 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.

30. When CPT Code 20550 (Trigger Point) is performed on the same day, allow full fee for first injection, fifty percent (50%) for the second, and twenty-five percent (25%) for the remaining procedures.

31. CPT Codes 20600, 20605, and 20610 should be allowed full fee for each procedure if performed in separate surgical fields; if in same surgical field, allow full fee for first fifty percent (50%) for the second, and twenty-five percent (25%) for the remaining procedures.

32. CPT Code 36415 (Routine Venipuncture) should be allowed in addition to office visit if the physician charges a fee.

33. The N.C. Industrial Commission Liaison Committee met on March 13, 1997 in Durham, NC, and discussed the Spinal Cord Stimulator. The Food and Drug Administration (FDA) has approved this procedure; therefore; it is the Commission’s position that this procedure is acceptable, providing the Medical Provider feels the procedure will benefit the injured employee. (G.S. §97-25).

The Committee and the N.C. Industrial Commission feel this procedure should be reviewed on a case-by-case basis by the Insurance Companies and the Medical Providers.

34. Changes in allowance for Diskectomy and additional spaces, when performed in conjunction with a fusion, will be changed effective June 1, 1997. Surgeries rendered on June 1, 1997 and thereafter will be approved as follows:

1. Allow full fee for fusion and additional space. (CPT Codes 22554 and 22585).

2. Allow fifty percent (50%) for Diskectomy (CPT Codes 63075 and 63076).

35. 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.

36. When processing Hospital bills for Ambulatory Surgery, use CPT Code 490 and code as outpatient. These bills are approved in full.

37. CPT Code 76140—Consultation on X-ray examination made elsewhere is not allowed if an office visit is charged. This charge should be included in with the visit. If submitted separately and no office visit, you may allow this charge.

38. a) Correct paragraph three (3) in the SURGERY Section on page 2 to read:

Multiple surgical procedures performed through the same incision will have the unit value of the major procedure. The secondary or lesser procedure(s) or service(s) may be identified by adding modifier -51 to the secondary procedure. You will be allowed 50% for the additional procedures based on the Medical Fee Schedule allowance.

b) Correct paragraph four (4) in the SURGERY Section on page 2 to read:

Multiple operative procedures performed at the same session in separate operative fields and through separate incisions are allowed total Medical Fee Schedule value for each procedure. The second procedure is identified by a modifier -50.

39. The Industrial Commission asked Medicode to research CPT Codes 90726 and 90742. 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 must be attached to the bill to verify the cost. We allow a 20 percent (20%) markup above the cost. If charged, the professional reimbursement for the injection procedure should be reimbursed at the value of procedure code 99211.

40. The Industrial Commission has given permission for the processor to pay bills that are listed as "BY REPORT" if charges don’t exceed $50.00 without submitting them to the Industrial Commission.

41. 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.

Effective January 1, 1993, Chiropractors may use code 99070 for supplies and also the codes we have assigned in our Medical Fee Schedule, if they so choose. See the Medical Fee Schedule for the correct codes. There is no allowance for vitamins.

1. We have assigned our own codes for this medical procedure group. They are allowed only thirty (30) visits with prior approval from their employer/insurance company. After thirty (30) visits, additional visits must be approved by their employer/insurance company.

2. Their codes must be used in entering all bills. They are allowed only two (2) therapy visits per day. Do not enter time for physical therapy. (See Medical Fee Schedule for codes.)

3. We require that they bill all services rendered on a daily basis.

4. All X-rays taken by a Chiropractor will require a modifier.

5. If the Chiropractor has approval from the employer to treat, the Insurance Company/Self-Insurer may not terminate the treatment until thirty (30) visits have been used. They may send employees to a physician of their choice, but the patient may continue up to thirty (30) visits.

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
PSY02      Return visit         time required
PSY03      Testing               time required
PSY04      Group                time required

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.

Enter the same way as others. You will find they will use only a four-digit code, so always add a "0" before each code. Some dentists will insert all five digits and others will not.

MC001      Non-Paid services—no allowance
MC002      Miscellaneous approved services
MC003      No show appointment—no allowance
MC004      Follow-up days included—no charge allowed (follow-up days are listed in the Medical Fee Schedule by each surgery code)
MC005      Unauthorized provider
FS100        Flow meter             $100.00 per day
FS200        Flap monitoring       $100.00 per day
CS100       Cold study              $100.00

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.

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

As stated above, key Rehabilitation Nurses bills in as RN100 and the total charged. This information will be required on the Form 51.

All "BY REPORTS" must be sent to the Chief Medical Fee Examiner marked "PERSONAL". These bills will be entered on our computer and returned to the Insurance Company or Self-Insurer. If they have someone processing their medical bills for them, it will be the responsibility of the Self-Insurer/Insurance Company to get the bill to them.

At this time, all inpatient hospital bills must be submitted to the Commission for processing.

Permission has been granted to pay charges for hospital outpatient facility fees and outpatient ancillary charges at five percent (5%) less than charges billed if you have been approved by the Commission to process bills.

The 1996 N.C. Industrial Commission Medical Fee Schedule may be purchased through Medicode. (800) 765-6023.

N.C. Industrial Commission
Medical Department
430 North Salisbury Street
Raleigh, NC 27611
(919) 733-5055

ABBREVIATIONS: * = starred procedures subject to special rules (see surgery section of Fee Schedule); ** = starred procedures subject to special rules; BR = by report; FUD = follow-up days; NA = no allowance; NACB = no allowance, continue billing as in the past; PC (26) = professional component; and TC (27) = technical component.

ABBREVIATIONS: * = starred procedures subject to special rules (see surgery section of Fee Schedule); BR = by report; FUD = follow-up days; PC (26) = professional component; and TC (27) = technical component.

ABBREVIATIONS: BR = by report; FUD = follow-up days; PC (26) = professional component; and TC (27) = technical component.

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