1. Where can a medical provider go for information on workers’
Industrial Commission web site: http://www.ic.nc.gov/.
The Publications Section contains the Fee Schedule and
Rating Guide. The
Bulletin is a great source of information. Also,
see Frequently Asked
Questions. The General Statutes and
Rules are also
available on-line. Under Search, there is a tool to search for the carrier: http://www.ic.nc.gov/iwcnss/.
To purchase a complete copy of the American Medical Association’s Current Procedural Technology Codes, telephone OptumInsight™ at (800) 464-3649, option 1, or go to http://www.optumcoding.com/ to order a CPT® code book online.
2. How can a medical provider verify workers’ compensation coverage?
An injured workers’ word is not sufficient. Contact the employer or better yet the workers’ compensation carrier. Carrier information can be found on the North Carolina Industrial Commission website or by contacting the Claims Administration Department at (919) 807-2502.
provides and directs medical treatment?
The employer or its insurance company, subject to any Commission orders, provides and directs medical treatment. The Commission may permit the employee to change physicians or approve a physician of employee’s selection when good grounds are shown. However, payment by the employer or carrier is not guaranteed unless written permission to change physicians is obtained from the employer, carrier, or Commission before the treatment is rendered.
should a medical provider send the bill for payment?
The bill, along with the medical records, should be sent certified mail, return receipt requested, to the employer, self-insured employer, or the workers’ compensation insurance carrier. Keep the receipt as proof of mailing.
5. How long does a medical provider have to submit a bill?
A provider of medical
compensation shall submit its statement for services within 75 days of the
rendition of the service or if treatment is longer, within 30 days after the end
of the month during which multiple treatments were provided, or within such
other reasonable period of time as allowed by the Industrial Commission.
However, in cases where liability is initially denied but subsequently admitted
or determined by the Industrial Commission, the time for submission of medical
bills shall run from the time the health care provider received notice of the
admission or determination of liability.
6. Are there certain field elements that are required on a workers’ compensation
Yes, the date of injury must be in the “date of occurrence” or “date of current” field. Also, the name, address, and telephone number of the employer and employee is a mandatory requirement. See Form Section 16 for more information.
7. Why should a claimant file a first report of injury to the North
Carolina Industrial Commission? Can’t they depend on the employer to do it for
The employer is required by law to file this Form 19, but the filing of the Form 19 does not satisfy the employee’s obligation to file a claim. The employee must file a Form 18 even though the employer may be paying compensation without an agreement, or the Commission may have opened a file on this claim.
8. How would a medical provider know if the North Carolina Industrial
Commission has jurisdiction on a workers’ compensation case?
The medical provider should send an inquiry note or letter (on company letterhead), with proof of the bill attached, to the employer and/or insurance carrier by certified mail, return receipt requested. If there is no response in 60 days, the provider can find carrier information on our web site at http://www.ic.nc.gov/iwcnss/ or contact the Claims Administration Section at (919) 807-2502 to obtain carrier information. If the North Carolina Industrial Commission is unable to locate a claim, then the employee may be billed until he or she files the Form 18 to report the injury.
9. What is a “medical only” claim?
This type claim means that there is no more than one day of lost time, no disfigurement or impairment, and no more than $2000.00 in medical expenses. The North Carolina Industrial Commission does not require the employer/carrier to submit the Form 19 for these claims, so there is no Industrial Commission file number created. The injured worker must file a Form 18 to create an I.C. file number in order to settle a dispute or request a hearing.
10. What does a medical provider do if they feel medical reimbursement is
Attempt should be made to resolve dispute with payer. Unresolved disputes should be submitted to the North Carolina Industrial Commission Medical Fees Section with a carbon copy to the payer. Submitted information should include the following:
letter on company letterhead explaining the dispute
Copies of bill
Copies of medical reports related to dispute
Copy of the payer’s previous explanation of payment
Copy of the certified mail return receipt confirmation
Any additional documentation felt to be related to issue
11. Will a medical provider receive 100% reimbursement for every bill?
No. They will be reimbursed as follows:
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:
- The lower end cap of the DRG band for reimbursement of inpatient hospital bills will be adjusted from 77.07% to 75% of charges for hospitals other than critical access hospitals. (Critical access hospitals are defined by federal law and are the smallest hospitals in the State, located in rural areas.)
- The reimbursement rate for outpatient hospital bills will be adjusted from 95% of charges to 79% of charges for hospitals other than critical access hospitals. For critical access hospitals, the outpatient reimbursement rate will be reduced from 95% to 87% of charges.
- The reimbursement rate for ambulatory surgical centers will be adjusted from 100% of charges to 79% of charges.
Prior to July 27, 2009:
- Outpatient hospital claims will be reimbursed at 95% of charges.
- Ambulatory surgical services will to reimbursed at 100%.
- Inpatient bills will be calculated by the North Carolina Industrial Commission’s 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 adopts a new reimbursement methodology.
- Contracts with payors could subject providers to different reimbursement procedures other than described above.
12. Can a medical provider ever bill a workers’ compensation claimant for
N.C. Gen. Stat. §97-90 (e): “A health care provider shall not pursue a private claim against an employee for all or part of the costs of medical treatment provided to the employee by the provider unless the employee’s claim or the treatment is finally adjudicated not to be compensable or the employee fails to request a hearing after denial of liability by the employer.” (Note 1: Employers/carriers are responsible for paying for authorized services up and to the point of the denial. Note 2: If a claim is denied by the workers’ compensation payer and the injured worker appeals to the Commission, the provider must wait until a decision is reached. If the Commission agrees that the claim is not compensable, then the provider can bill the injured worker.)
13. Does the treating physician have to notate a return to work date?
Yes. The physician is required to report on a HCFA-1500: whether the patient’s treatment is terminated; the date the injured is able to return to work; “none” if there is no permanent disability; and if there is permanent partial disability, the nature and extent of such permanent disability.
14. When does the treating physician need to document the specific
disability impairment rating?
At the end of the healing period.
15. Is there a specific form for reporting the impairment rating?
Yes, Form 25R.
16. Can a medical provider ever appeal for more than the fee schedule
Rule 407 allows appeal in hardship cases. “However, in special hardship cases where sufficient reason is demonstrated to the Industrial Commission, fees in excess of those so published may be allowed.” Appeal would be made to the North Carolina Industrial Commission with a copy going to all other parties.
17. How would a physician bill an Independent Medical Evaluation?
The Commission has created special coding for review of medical records when an IME is conducted. Along with the special code, the provider may bill an office visit code if an examination is performed. Keep in mind that an IME may involve the examination portion, but always includes a comprehensive review of records, and a full report (reference Section 16). A second opinion on an impairment rating is not an Independent Medical Evaluation, as the rating is just one component of the IME. (CPT code 99456 would be appropriate for the second opinion rating only.)
HIPAA regulations change the procedure of sending medical records with the
workers’ compensation bill?
No, HIPAA law does not preempt state
law on workers’ compensation and should not impede the process. “§164.512
Uses and disclosures for which consent, an authorization, or opportunity to
agree or object is not required. (l) Standard:
disclosures for workers’ compensation. A covered entity may disclose
protected health information as authorized by and to the extent necessary to
comply with laws relating to workers’ compensation or other similar programs,
established by law, that provide benefits for work-related injuries or illness
without regard to fault.”
19. Can a medical provider ever charge for copying
medical records in a workers’ compensation case?
Medical providers are responsible for providing one free copy of medical records to the first requesting party among the following: employers, carriers, third party adjusting agencies, and rehabilitation nurses. Medical providers may charge a reasonable fee for providing medical records to each subsequent requesting party. Medical providers may always charge a reasonable fee for providing medical records to the employee or the employee’s attorney or other representative. The Industrial Commission has established what such reasonable fee shall be. In no event will it be more than 50 cents per page for the first 40 pages and 20 cents per page for each page above 40, submit to a minimum fee of $10. Such fee covers searching handling, copying and mailing.
20. Does the Fee Schedule address information that should be included in
Yes. See the abstract from Section 16.
the Medical Provider:
Information to be included in Reports of Special Examinations
For your information and as a guide in completing reports of special examinations, the following information is essential and should be incorporated in your written reports.
1. History of case as obtained from you from the injured (note any pre-existing injuries or diseases).
2. Injured’s symptoms and complaints as obtained by you.
3. Physical findings (this is to include laboratory, x-ray, etc.). Include measurements of function according to accepted standard of the American Medical Association Guides.
4. Diagnosis of condition or conditions found.
5. Your opinion as to the relation between condition or conditions diagnosed and the injured’s alleged injury or occupational exposure, with your reasons for your opinion.
6. Whether any temporary disability exists; if so, whether it is total or partial, and its probable duration.
7. What physical impairment, if any, can be expected.
8. Where permanent disability has resulted and the case is ready for permanent disability rating, the extent of impairment should be given in detail. Where measurements can be taken and can be related to the corresponding opposite measurement, both measurements should be given as a fraction of injured over uninjured. If both sides are involved in the injury, then any estimate of the normal measurement should be given. If a part of the disability is attributable to a prior injury or disability, the extent to which the present impairment is affected by the prior condition must be given and may be expressed as a percentage; i.e., 50% of impairment due to injury; 50% due to preexisting factors.
9. What treatment, if any, is indicated, including type, frequency, and probable duration.
10. Any other medical information that you believe pertinent to the case, to assist in making an equitable adjustment.
11. Give date patient in your opinion should be able to return to work or actual date of return if known.
Information to be included in Progress Reports
1. Date of most recent examination.
2. Present condition and progress since last report.
3. Measurements of function.
4. X-ray or laboratory report since last examination.
5. Treatment—type, duration.
6. Work status—patient working or estimated date of return to work.
7. Permanent impairment to be anticipated.”
21. How are supplies paid?
The North Carolina Industrial Commission has adopted nearly 1100 HCPCS billing codes to describe supplies and equipment used in workers’ compensation treatment. However, the Commission has not yet incorporated into its fee schedule all of the HCPCS level codes for supplies and equipments. For example, none of the “J” codes have been adopted. If a supply is billed, and the code does not have a fee assigned in the Commission schedule, the provider is entitled to 20% above invoice cost.
The Commission will allow a provider to use CPT code 99070 when billing for supplies or equipment that are not designated in the Workers’ Compensation Medical Fee Schedule. The provider is entitled to cost plus 20%.
If a custom-made orthotic or prosthetic is not contained in the Commission schedule, these items should be paid per agreement between provider and payer.
are new procedures like Sonorex paid?
Always check with the Commission to be sure. Sonorex or extracorporeal shockwave therapy should be paid by agreement.
does a medical provider know if an assistant surgeon fee is allowed?
Medical providers are to follow the American Medical Association’s CPT guidelines. You may also see the On-line Fee Schedule at http://www.ic.nc.gov/ncic/pages/amalicen.htm and click the CPT/Codes, then the Assistant Surgeon Guide.
the bilateral codes listed in the Commission’s Table of Bilateral Codes
(Surgery Section) the only codes that will be paid at 150% when performed
The medical providers are to follow the American Medical Association’s CPT guidelines that identify several codes that could be coded as bilateral. CPT codes 64475 and 64476 are prime examples.
the decision to perform surgery E&M service considered global to the
No, the global period begins with the surgery. The decision to perform the surgery (identified by modifier 57) is paid separately.
there special guidelines concerning casting?
When a physician performs an evaluation and management service followed by the treatment of a fracture, both service codes may be billed and shall be reimbursed.
Casting codes are not used in conjunction with fracture care, but may be used in a stand-alone setting, i.e., recast or cast without fracture care.
Casting materials may be billed separately in conjunction with initial or subsequent casting and should be reimbursed according to the Commission’s guidelines for payment of supplies.
a provider be reimbursed for CPT code 76005 (fluoroscopic guidance) when
performing diagnostic or therapeutic injections involving the spine or
Yes, separate reimbursement is allowed, but only once per day.
28. When can a Physical Therapist or Occupational Therapist bill for
The following represents when a physical therapist or occupational therapist may bill for a reevaluation. The appropriate codes would be 97002 for physical therapy reevaluation and 97004 for occupational therapy reevaluation.
There is a definitive change in the patient’s condition
The patient fails to respond to treatment and there is a need to change the treatment plan.
The patient has completed the therapy regimen and is ready to receive discharge instructions
The North Carolina Industrial Commission will allow use of CPT code 97001 for initial physical therapy evaluations or 97003 if the initial evaluation is for occupational therapy. This code may be used along with modalities performed the same day.
there special requirements to be reimbursed for consultation codes?
Yes, check AMA and other coding guides, but it is essential that the consultative physician report findings back to the requesting party or physician. When the treating physician transfers the complete care to another physician the Commission considers this a referral and not a consultation. The new physician would bill a new patient visit.
a medical provider bill for administering an intramuscular injection?
Only if an office visit is not charged. See the Medical Fee Schedule, Medicine Section for more information.
a medical provider expect separate reimbursement for electrodes in conjunction
with nerve conductions studies?
No, the cost of the electrodes is built into the procedure’s reimbursement.