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©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided.

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Presentation on theme: "©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided."— Presentation transcript:

1 ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided by Coventry Health Care ® Arizona Medical Bill Reviewer Training Program Introduction and General Guidelines

2 2 Arizona Regulation Training-Introduction Overview Hi! Im here to guide you on a tour of the Arizona Workers Compensation fee schedule rules. Together Im sure we can become more familiar with the unique aspects of our guidelines. Part I: General Information History Part II: Processing Guidelines Separate Procedures Unlisted Procedures Locator Codes Modifiers Calculating Reimbursements

3 3 Arizona Regulation Training-Introduction History In 1925, the Arizona Legislature passed the States first Workers Compensation Act and the Industrial Commission was established to administer that compensation law. Workers Compensation is a no-fault system. Which workers are covered? Seasonal Part-time Employees of non-profit organizations Employees of unincorporated businesses

4 4 Arizona Regulation Training-Introduction Arizona Workers Compensation Act Industrial Commission The Industrial Commission is responsible for deciding disputes and monitoring the activities of the State Compensation Fund, private carriers and self-insured employers. The Industrial Commission is composed of five members appointed by the governor. The chairman of the commission shall be appointed by and serve at the pleasure of the governor. Lawsuits against the employer, except under very limited circumstances, are not permitted.

5 5 Arizona Regulation Training-Introduction Arizona Workers Compensation Act Types of Claims There are two types of Workers Comp claims: Medical Only - only medical expenses are paid. Time Lost – medical expenses and temporary compensation benefits for lost wages are paid.

6 6 Arizona Regulation Training-Introduction Arizona Workers Compensation Act The Arizona Workers Compensation Act provides for: Benefits are paid by: Medical expenses Wage-loss compensation benefits Death benefits for work-related deaths paid to dependent survivors Private insurance companies Employers themselves, if self- insured Special Fund of the Industrial Commission

7 7 Arizona Regulation Training-Introduction Arizona Workers Compensation Injured Workers Labor Unions Insurance Companies Employers Attorneys Service Providers Regulation Agencies The Workers Compensation Program is a large melting pot of many different entities.

8 8 Arizona Regulation Training-Introduction General Information and Instructions Part I: General Information History Part II: Processing Guidelines Locator Codes Calculating Reimbursements Separate Procedures Procedures Without Unit Value Modifiers Now that you are familiar with the framework of Arizona Workers Comp, lets take a look at some processing guidelines & instructions...

9 9 Arizona Regulation Training-Introduction Locator Codes These codes are used to determine how the Fee Schedule pricing is applied. The code is determined by zip code location and impacts both professional and facility bills. There is one locator code that applies to all Arizona zip codes – 999. Lets take a look… How could I find the Arizona locator code?

10 10 Arizona Regulation Training-Introduction Locator Codes Step 1: Select Bill Review 4 Reference Materials

11 11 Arizona Regulation Training-Introduction Locator Codes Step 2: Choose State Reference Guides

12 12 Arizona Regulation Training-Introduction Locator Codes Step 3: Select Fee Schedule Locality Tables under Internal Resources on the right side of the screen.

13 13 Arizona Regulation Training-Introduction Locator Codes Step 4: Click Open to view the Locality Tables Spreadsheet

14 14 Arizona Regulation Training-Introduction Locator Codes Step 5: Select the WC FS Locations tab to view the locations.

15 15 Arizona Regulation Training-Introduction Arizona Zip Codes – Step 6: Scroll down to the Arizona Zip Codes starting with The Locality for all Arizona Zip Codes is 999.

16 16 Arizona Regulation Training-Introduction Changing a Billed Procedure Code Altering codes is allowed per state guidelines. Key billed procedure in the Billed Proc field.

17 17 Arizona Regulation Training-Introduction Balance Billing Balance Billing is prohibited by Arizona. The injured worker is not responsible for payment of any portion of a medical bill on an accepted claim or payment of any portion of a medical billing that is being disputed.

18 18 Arizona Regulation Training-Introduction Separate Procedures Some listed procedures are carried out as an integral part of a total service, while other procedures are independent of additional services. Procedures that are integral parts of a total service DO NOT warrant separate identification or reimbursement. Separate Procedure: a procedure independent of, and not immediately related to, other services performed, for which reimbursement is ALLOWED. Lets take a look…

19 19 Arizona Regulation Training-Introduction Separate Procedures For Example: CPT 95851, which codes for a Range of Motion procedure, is an essential part of a follow up visit for a shoulder injury. Therefore, it WOULD NOT warrant separate reimbursement. However, if this procedure were the only service performed, it would be considered a separate procedure and should be ALLOWED.

20 20 Arizona Regulation Training-Introduction If the necessity of the services has been verified, and the service authorized, additional information may be requested about the procedure, or an online search may be performed. Unlisted Procedures By Report (BR) Relatively Not Established (RNE) Every effort should be made to identify the service performed with a specific code rather than an unlisted procedure. The unlisted code billed may represent a slightly different version of an established code which would still be appropriate. Procedure codes that do not have a listed value will be recommended for payment at states listed guidelines. Key as billed.

21 21 Arizona Regulation Training-Introduction Unlisted Procedures By Report (BR) Relatively Not Established (RNE) Every effort should be made to identify the service performed with a specific code rather than an unlisted procedure code. As you know, providers often misuse the unlisted code when a more appropriate code is available. Hmm, which code should I use?

22 22 Arizona Regulation Training-Introduction Service (SV) Items In the Arizona Fee Schedule, there are some Procedure codes with a value of SV. This value is to be calculated as the sum of the various services rendered according to the ground rules covering these services. Example Services: office, home, nursing home or hospital visits, consultation or detention. When the edit sets requiring manual review, follow the narrative instructions.

23 23 Arizona Regulation Training-Introduction Shipping, Handling Charges, Sales Tax There are no state specific reimbursement regulations where shipping, handling, and/or sales tax are mandated or allowed for the state. Key as billed.

24 24 Arizona Regulation Training-Introduction Out-of-State Bills Bills for out-of-state services will be recommended for payment according to the rules set up for each client, whether it is claimant domicile, provider domicile, or state specific. Key services as billed.

25 25 Arizona Regulation Training-Introduction Modifiers Modifiers indicate that a procedure was altered by additional circumstances, but was not changed from its standard definition. Modifiers may indicate circumstances such as: Only part of the whole procedure was performed. A bilateral procedure was performed. Modifiers are covered in the context of billed codes.

26 26 Arizona Regulation Training-Introduction Modifiers Modifier 17 is used by Arizona for minor surgical procedures that are conducted in the office in lieu of an Outpatient Ambulatory Care Center. An add-on fee is permitted that would allow an additional fee of 25% of the surgical procedure, not to exceed $ When billed with modifier 17 and the capped amount has been met (greater than $300.00), an edit will set requiring you to manually apply the capped amount. Follow the narrative instructions.

27 27 Arizona Regulation Training-Introduction Modifiers Modifier 22 i s used by Arizona for Increased Procedural Services. An add-on fee is permitted that would allow an additional fee of 25% of the unusual service.

28 28 Arizona Regulation Training-Introduction Calculating Reimbursements Reimbursement rates are tied to values published in the official Arizona fee schedule. It is important to know that the Bill Review system calculates and applies these reimbursements for you. But, as you can see, knowing how to calculate reimbursements may help you identify errors during bill review or troubleshoot problems when reviewing challenging bills.

29 29 Arizona Regulation Training-Introduction Summary How reimbursements are calculated. Description of modifiers, separate procedures and unlisted procedures. Defined Locator Codes Arizona Workers Comp Overview.


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