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

2. Texas Regulations TrainingAugust 2011 2 Overview Howdy, I’m here to guide you on a tour of our Workers’ Compensation fee schedule rules. Together I’m 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  Special Reports  Modifiers  Calculating Reimbursements

3. Texas Regulations TrainingAugust 2011 3 History In 1913, Texas’s Workers’ Compensation laws were established. At the same time, the Texas Industrial Accident Board was created to administer the laws. When the law was established, employers were allowed to choose whether to offer workers' compensation benefits to their employees.

4. Texas Regulations TrainingAugust 2011 4 Texas Workers’ Compensation Act In 1917, Texas revised its workers' compensation laws to require employers to choose whether or not to participate in a state workers' compensation program. Texas is the only state that allows employers to choose whether or not to provide workers' compensation. However, one exception exists: Employers entered in a building or construction contract with a government entity must provide workers' compensation for all workers.

5. Texas Regulations TrainingAugust 2011 5 TX Workers’ Compensation Act The Texas 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 (including TPAs)  State Workers’ Compensation Fund (a state-run workers’ comp carrier)  Employers themselves, if self insured

6. Texas Regulations TrainingAugust 2011 6 Texas 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.

7. Texas Regulations TrainingAugust 2011 7 General Information and Instructions Part I: General Information History  Part II: Processing Guidelines  Locator Codes  Calculating Reimbursements  Separate Procedures  Procedures Without Unit Value  Special Reports Now that you are familiar with the framework of TX Workers’ Comp, let’s take a look at some general guidelines and instructions.

8. Texas Regulations TrainingAugust 2011 8 Locator Codes Texas has 1 locator code in the BR4 system – 999 The code is determined by zip code location and impacts both professional and facility bills. Let’s take a look... How do I find a locator code?

9. Texas Regulations TrainingAugust 2011 9 Locator Codes Step 1: Access Bill Review 4 Reference Materials

10. Texas Regulations TrainingAugust 2011 10 Locator Codes Step 2: Select State Reference Guides & U&C Guidelines.

11. Texas Regulations TrainingAugust 2011 Locator Codes Step 3: Select Locality Tables under Internal Resources on the right side of the screen.

12. Texas Regulations TrainingAugust 2011 Locator Codes Step 4: Find the provider’s zip code and the effective date of service on the table to locate the provider’s fee schedule locality.

13. Texas Regulations TrainingAugust 2011 13 Changing a Billed Procedure Code  There is a reluctance with most workers’ compensation departments and boards to allow payors to change billed codes.  This is seen as a possible way to manipulate payment without the provider’s permission.  In Texas, however, altering codes is allowed if the provider is called and notified of the change. Key the billed procedure in the Billed Proc field. Let’s take a look at an example

14. Texas Regulations TrainingAugust 2011 14 Changing a Billed Procedure Code On this bill example, there is a Surgical DRG, a CPT code, which is billed for the Total Technical and Professional component and a surgical Revenue code. CPT Code Surgical DRG Surgical Rev Code

15. Texas Regulations TrainingAugust 2011 15 Changing a Billed Procedure Code To change the code in the system, change the CPT code for the Technical component to the appropriate Revenue code by taking the following steps: Line 4: CPT code 73500 billed as Total component (no modifier) Line 4: change CPT code 73500 to Professional component (modifier 26) Line 6: Rev code 320 keyed for the Technical component of 73500

16. Texas Regulations TrainingAugust 2011 16 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.

17. Texas Regulations TrainingAugust 2011 17 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 was the only service performed, it would be considered a separate procedure and should be ALLOWED.

18. Texas Regulations TrainingAugust 2011 18 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 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 that would still be appropriate.

19. Texas Regulations TrainingAugust 2011 19 Unlisted Procedures 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?

20. Texas Regulations TrainingAugust 2011 20 Out-of-State Bills All Texas claims, both in- state and out-of-state, are paid by Texas WC fee schedule rules and values.

21. Texas Regulations TrainingAugust 2011 21 Special Reports Special Reports (CPT 99080) are reports specifically requested by the insurer. Only certain types of reports are reimbursable. Follow the edit instructions. Special Reports

22. Texas Regulations TrainingAugust 2011 22 Special Reports If this procedure code is keyed: For this item:The system recommends: 99080, with modifier 69 Texas DOWC-69, Report of Medical Evaluation Denial of charges 99080, with modifier 73 Work Status Report$15.00 99080Narrative Report$100.00 for the first two pages, $40.00 per additional page 990801-2 page single spaced report $50.00 for the first page

23. Texas Regulations TrainingAugust 2011 23 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 will be covered in the context of billed codes.

24. Texas Regulations TrainingAugust 2011 24 Calculating Reimbursements Reimbursement rates are tied to Medicare rates. All CPT and HCPCS codes are based on the 2011 Medicare values. DME codes are based on the 2011 DMEPOS fee schedule guidelines.

25. Texas Regulations TrainingAugust 2011 25 Calculating Reimbursements It is important to know that the bill review system calculates and applies the 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.

26. Texas Regulations TrainingAugust 2011 26 Summary Description of separate procedures and unlisted procedures Defined special reports How to calculate reimbursements TX Workers’ Comp Overview