FLORIDA WORKERS COMPENSATION REIMBURSEMENT MANUAL FOR AMBULATORY SURGICAL CENTERS

Transcription

1 FLORIDA WORKERS COMPENSATION REIMBURSEMENT MANUAL FOR AMBULATORY SURGICAL CENTERS 2006 Edition Florida Department of Financial Services Division of Workers Compensation for incorporation by reference into Rule 69L-7.100, Florida Administrative Code

2 NOTICE AND DISCLAIMER The Florida Workers Compensation Reimbursement Manual for Ambulatory Surgical Centers, 2006 Edition, includes five character identifying codes and modifiers selected from the Current Procedural Terminology (CPT ), 2007 Professional Edition, Copyright 2006, American Medical Association. The CPT (and updates thereto) are the property of the American Medical Association (AMA), and are developed by the AMA for use by physicians, hospitals, ambulatory surgery centers, etc., for reporting physician performed medical services and procedures. Reference to CPT that is not included in the Florida Workers Compensation Ambulatory Surgical Centers Reimbursement Manual, 2006 Edition, should be to the most recent CPT. Applicable FARS/DFARS apply. Similarly, reference to identifying codes and modifiers, when applicable for dental and health care common procedure coding system, shall be made to Current Dental Terminology, CDT-2007/2008, Copyright 2006, American Dental Association, and HCPCS 2007, Nineteenth Edition, Copyright 2006, Ingenix Publishing Group. The CPT, CDT- 2007/2008, and HCPCS are incorporated by reference into rule 69L-7.100, Florida Administrative Code. The CPT is a commercial technical data and/or a computer databases and/or a commercial computer software and/or a commercial software documentation, as applicable, that are developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS (b)(2) (June 1995) and/or subject to the restrictions of DFARS (a) (June 1995) and DFARS (a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR (June 1987) and/or subject to the restricted rights provisions of FAR (June 1987) and FAR (June 1987), as applicable, and any applicable agency FAR Supplements, for non-department of Defense Federal procurements. It is expressly understood and agreed that the AMA reserves and maintains all literary property rights over the CPT and in any update thereto, whether statutory or by common law, and that no rights have been assigned or released as a result of the agreement between the AMA and the State of Florida regarding use of the AMA s CPT publication. The responsibility for the content of the Florida Workers Compensation Reimbursement Manual for Ambulatory Surgical Centers, 2006 Edition, is solely with the State of Florida Division of Workers Compensation and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in the Florida Workers Compensation Reimbursement Manual for Ambulatory Surgical Centers, 2006 Edition. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of the CPT. RULE 69L-7.100, F.A.C. ii

3 TABLE OF CONTENTS SECTION TITLE PAGE Section I Administrative Purpose of Manual 1 Section II Applicability 1 Section III Authorization 1 Section IV Materials Adopted for Reference 2 Section V Managed Care 2 Section VI Medical Records Maintenance and Disclosure; Copy and Duplication Charges Section VII Out-of-State ASC Facility 3 Section VIII Billing 4 Section IX ASC Facility Services and Surgical Implants 5 Section X Non-ASC Facility Services 5 Section XI Pathology/Laboratory and Radiology/Imaging Services Section XII Determination of Reimbursement 7 Section XIII Reimbursement for Multiple Procedures 9 Section XIV Terminated Procedures 10 Section XV Charge Master and Medical Record Review or Audit 11 Section XVI Listed Schedule of Maximum Reimbursement Allowances 12 Section XVII Disallowed, Denied and Disputed Charges 13 Appendix A Modifiers 14 Appendix B Definitions 16 Appendix C Rule 69L-7.100, Florida Administrative Code 19 Index Index RULE 69L-7.100, F.A.C. iii

4 SECTION I: ADMINISTRATIVE PURPOSE OF MANUAL The administrative purpose of the Florida Workers Compensation Ambulatory Surgical Centers Reimbursement Manual, 2006 Edition, is to furnish Florida workers compensation health care providers with general information, reimbursement policies and maximum reimbursement allowances (MRA) for covered Ambulatory Surgical Centers (ASC) facility services. SECTION II: APPLICABILITY All requirements in this Manual specifically apply to services that are furnished in an independent or freestanding ASC licensed in accordance with Chapter 395, F.S. SECTION III: AUTHORIZATION A. Florida ASC facilities and out-of-state ASC facilities must be authorized by the employee s workers compensation insurer or a self-insured employer prior to rendering initial and remedial medical services or before referring the injured employee to facilities or other certified health care providers. B. Insurers must comply with the statutory requirements in s , F.S., in responding to authorization requests timely and to ensure that ASC facilities are eligible to receive reimbursement for the treatment being requested. C. Neither emergency services and care, defined in s , F.S., nor a provider referral for emergency treatment resulting from emergency care, require authorization by an insurer. These are the only exceptions to the requirements of prior authorization for medical care and treatment. D. ASCs shall record the authorization in the injured employee's medical record or in the ASC s billing or financial record(s) and shall include: 1. The date(s) on which authorization was requested and received (whether verbally or in writing); and 2. The name of the insurer or its designated entity, and the person authorizing the ASC services. 1

5 SECTION IV: MATERIALS ADOPTED FOR REFERENCE The following publications are incorporated by reference into rule 69L-7.100, Florida Administrative Code (F.A.C.), to be used in conjunction with this Manual for adopted by reference to with listings of descriptive terms and identifying codes for reporting medical services and procedures provided to injured employees by ASCs, Ambulatory Surgical Centers and are available as directed in rule 69L-7.100, F.A.C.: A. Current Procedural Terminology (CPT ), 2007 Professional Edition, Copyright 2006, American Medical Association. B. Current Dental Terminology (CDT-2007/2008), Copyright 2006, American Dental Association. C. Healthcare Common Procedure Coding System, Medicare s National Level II Codes, HCPCS 2007, Nineteenth Edition, Copyright 2006, Ingenix Publishing Group, for dental D codes, injectable J codes, and the other medical services or supply codes as specified in this Manual. D. Florida Workers Compensation Health Care Provider Reimbursement Manual, 2006 Edition. SECTION V: MANAGED CARE An ASC facility may enter a workers compensation managed care arrangement to provide care and services for an agreed upon contract price. The terms of an agreement may follow the specific requirements of this Manual or may contain additional or different requirements. SECTION VI: MEDICAL RECORDS MAINTENANCE AND DISCLOSURE; COPY AND DUPLICATION CHARGES A. Copying Charges for Medical Records. 1. Injured employee. An injured employee or injured employee's attorney requesting copies of medical records shall reimburse the ASC for copying charges pursuant to s (4)(b), F.S., and rule 69L-7.601, F.A.C. No other copy charges or search charges may be charged to the injured employee or the injured employee s attorney as part of the services provided to the injured employee by the ASC. 2

6 2. Employer/Insurer. An insurer, employer or authorized representative requesting copies of medical records shall reimburse the ASC for copying charges pursuant to s , F.S. 3. Division/Agency for Health Care Administration/Judge of Compensation Claims. ASCs shall not be reimbursed any charges for copies of medical records required by the Division, the Agency for Health Care Administration, or a Judge of Compensation Claims in performance of their statutory duties implementing and enforcing the Workers Compensation Law. B. The limits on charges apply regardless of whether the retrieval and copying are performed in-house or contracted out for completion by a copy service or other medical record maintenance service, and also apply when the insurer requires ASC medical records submission with a bill in order for payment to be made. The above charges apply to all copies of original documents requested by an insurer whether the request for the copies is made before services are rendered, after services are rendered, or in the course of an on-site audit or medical record review and whether the request for copies is for an entire document or for selected portion(s) of a document. SECTION VII: OUT-OF-STATE ASC FACILITY A. ASC services provided by an out-of-state facility require authorization from the insurer. B. An ASC outside of the state of Florida shall be reimbursed at either: 1. The amount agreed upon by the ASC and insurer during authorization; or 2. When no amount is pre-approved, the greater of the reimbursement established under Florida s Workers Compensation law or rules or the maximum payment amount provided under the workers compensation statute of the state in which the ASC is located. 3

7 SECTION VIII: BILLING A. There are three primary elements in the total cost of performing a surgical procedure in an ASC: 1. Professional Fee(s). The cost of professional services for performing the procedure; 2. Facility Fees. The cost of the facility services furnished by the facility where the procedure is performed (for example, the surgical supplies and equipment and nursing services); and 3. Surgical Implant Fee(s). The cost of surgical implants includes the cost of the surgical implant(s), the associated disposable instrumentation required for implantation received with and included on the acquisition invoice received by the ASC for the surgical implant(s), and, the shipping and handling included on the acquisition invoice. B. The Professional Fee(s) is billed according to the Florida Health Care Provider Reimbursement Manual and paid to the professional(s). The Facility Fee is paid to the ASC. The Surgical Implant Fee is paid to the ASC. C. The Facility Fees are billed according to the ASC s own charge master in accordance with the Florida Workers Compensation Medical Services Billing, Filing and Reporting Rule, rule 69L-7.602, F.A.C., utilizing CPT procedure and CDT codes. D. Surgical Implants are billed using procedure code and identified by appending the appropriate modifier IM, DI or SH. (See Section XII C. of this Manual.) E. ASC facilities shall submit their bills in accordance with the Florida Workers Compensation Medical Services Billing, Filing and Reporting Rule, rule 69L-7.602, F.A.C., available at the following website: (Rules and Forms). F. The use of codes and descriptions, modifiers, guidelines, definitions and instructions of the referenced CPT, CDT and HCPCS shall be used in part for dental codes, injection codes, specific modifiers, and the other medical services or supply codes as specified in this manual. 1. The use of Category III CPT codes for emerging technology, services and procedures must be used when available instead of a Category I CPT unlisted code. 2. The code descriptors, guidelines, definitions, and instructions of the aforementioned references are not provided in this manual. Any modification to a code descriptor by the workers compensation program shall be specified and shall take precedence over any descriptor contained in the referenced CPT, CDT or HCPCS. 4

8 SECTION IX: ASC FACILITY SERVICES AND SURGICAL IMPLANTS A. Facility services include all services and procedures furnished in connection with covered surgical procedures performed in an ASC. ASC facility services include the following, but are not limited to: 1. Nursing and technical personnel services and other related services; 2. Use of operating and recovery rooms, patient preparation areas, waiting room, and other areas used by the patient or offered for use by the patient s relatives in connection with surgical services; 3. Drugs, biologicals, surgical dressings, splints, casts, surgical supplies and equipment (required for both the patient and ASC personnel, e.g., gowns, masks, drapes, case pack, operating and recovery room equipment) commonly furnished by the ASC in connection with the surgical procedure. This category does not include Surgical Implants as specified in Section IX B of this Manual; 4. Diagnostic or therapeutic items and services (with respect to diagnostic tests, many ASCs perform simple test(s) just before surgery, such as urinalysis, blood hemoglobin or hematocrit which are generally included in the ASC s facility charges and are considered to be facility services); 5. Administrative, recordkeeping, and housekeeping items (i.e., administrative functions necessary to run the facility, such as scheduling, cleaning, utilities and rent); 6. Blood, blood plasma or platelets; (ASC procedures are limited to those not expected to result in extensive loss of blood, but in some cases, blood or blood products are required); and 7. Materials for anesthesia include the anesthetic itself, and any materials, whether disposable or reusable, necessary for its administration. B. Surgical Implants shall be billed separately and identified by appending the appropriate modifier IM, DI or SH to the five-digit procedure code and shall be reimbursed in accordance with Section XII, C of this Manual. SECTION X: NON-ASC FACILITY SERVICES A. Non-ASC facility services include a number of items and services reimbursable under the Florida Workers Compensation program that may be furnished in an ASC which are not considered facility services. 5

9 B. The following are examples of non-asc facility services that must be billed and reimbursed separately under provisions of the applicable fee schedule. 1. Physicians services; 2. Sale, lease, or rental of durable medical equipment to ASC patients for use in the patient s home; 3. Services furnished by an independent laboratory; and 4. Ambulance services. SECTION XI: PATHOLOGY/LABORATORY AND RADIOLOGY/IMAGING SERVICES Preadmission pathology/laboratory or radiology/imaging services, when required by the physician and performed by the ASC on a date other than the date of surgery, shall be reimbursed in accordance with the schedule of MRAs established for health care providers using the Florida Workers Compensation Health Care Provider Reimbursement Manual incorporated by reference into rules 69L and 69L-7.100, F.A.C. (See Section XI, General Instructions and Part C to obtain the MRA.) A. Pathology/Laboratory Services. 1. Pathology/laboratory services which are performed by the ASC on the day of admission shall be reimbursed separately according to Section XII of this Manual when billed under the appropriate 5-digit CPT code. 2. Venipuncture for the collection of a blood specimen that must be conveyed to an independent laboratory shall be reimbursed under procedure code 36415, in accordance with the schedule of MRAs established for health care providers using the Florida Workers Compensation Health Care Provider Reimbursement Manual incorporated by reference into rules 69L and 69L-7.100, F.A.C. (See Section XI, General Instructions and Part B to obtain the MRA.) 3. Pathology/laboratory services provided by an independent clinical laboratory shall be reimbursed directly to the laboratory service provider according to rule 69L-7.020, F.A.C. (See rule 69L-7.602, F.A.C., for billing instructions.) However, the ASC shall be reimbursed for procedure code for the collection of a blood specimen that must be conveyed to an independent laboratory. 6

10 B. Radiology/Imaging Services. Radiology/imaging services that are performed by the ASC on the day of the admission are reimbursed separately according to Section XII of this Manual when billed under the appropriate 5-digit CPT procedure code. SECTION XII: DETERMINATION OF REIMBURSEMENT A. For procedures with an MRA listed in Section XVI of this Manual, the ASC shall be reimbursed either the MRA or the agreed upon contract price. B. For procedures which are not listed in Section XVI of this Manual, the ASC shall be reimbursed either seventy percent (70%) of the ASC s charge or the agreed-upon contract price. C. For Surgical Implant(s): 1. Cost Formula. a. Surgical implants shall be reimbursed separately under procedure code with modifier IM appended. The associated disposable instrumentation required for implantation of a surgical implant shall be reimbursed separately under procedure code with modifier DI appended. The shipping and handling shall be reimbursed separately under procedure code with modifier SH appended. b. The ASC shall be reimbursed for the surgical implant(s) at fifty percent (50%) over the acquisition invoice cost. The ASC shall be reimbursed for the associated disposable instrumentation required for implantation of the surgical implant at twenty percent (20%) over the acquisition invoice cost, if the associated disposable instrumentation is received with the surgical implant and included on the acquisition invoice. The ASC shall be reimbursed for shipping and handling at cost, if included on the acquisition invoice. c. When determining the acquisition invoice cost for the surgical implant, the ASC shall subtract any and all price reductions, offsets, discounts, adjustments and/or refunds which accrue to or are factored into the final net cost to the ASC, only if they appear on the acquisition invoice, before increasing the invoice amount by the percentage factors described in subparagraph (b), and the ASC shall add the shipping and handling after increasing the invoice amount by the percentage factors described in subparagraph (b). 2. Documentation of Surgical Implant Acquisition Invoice Cost. In order to receive reimbursement for surgical implant(s) identified and billed in accordance with this Section, the ASC must submit to the insurer a copy of 7

11 the acquisition invoice that substantiates the cost of the item(s) or shall certify that the amount being requested for reimbursement has been determined in accordance with this Section. Charges for surgical implant(s) that are not separately billed under procedure code and identified by appending the appropriate modifier (IM, DI or SH) and that are not accompanied by invoice(s) or certification as provided in this Section, shall constitute undocumented charges. 3. Certification of Acquisition Invoice Cost for Surgical Implant(s). Certification that the amount requested for reimbursement for the surgical implant(s) has been determined in accordance with this Section may be submitted as follows: a. By written statement accompanying the request for reimbursement for surgical implant(s); b. Pursuant to prior written agreement between the billing ASC and the insurer regarding reimbursement for surgical implant(s); or c. Electronically via the ASC billing form pursuant to this Section. 4. Verification of Surgical Implant Costs and Charges. The ASC s certification of amounts requested for reimbursement pursuant to this Section, whether written, by prior agreement or electronically via the electronic ASC billing format, and the ASC s compliance with the billing requirements of rule 69L-7.602, F.A.C., shall be subject to verification through audit and medical record review pursuant to Section XV of this Manual. Upon request by either the Division, the Agency or an insurer, or its designee, to conduct an audit or medical record review under this Section, the ASC shall produce a copy for the requestor or make the original documents available for on-site review, or elsewhere by mutual agreement, such medical record(s) and surgical invoice purchasing documentation as requested within thirty (30) days of the request. When the ASC produces copies of requested documents, the insurer, or its designee, shall reimburse the ASC for copying charges pursuant to s F.S. When the ASC makes the requested documents available for review, the insurer, or its designee, shall not be charged for the review. Neither a request nor completion of an audit pursuant to this Section shall toll the time frame for petitioning the Agency for resolution of a reimbursement dispute pursuant to s (7), F.S. 8

12 SECTION XIII: REIMBURSEMENT FOR MULTIPLE PROCEDURES A. Reimbursement shall be made for all medically necessary surgical procedures when more than one (1) procedure is performed at a single operative session. 1. Each procedure performed shall be identified by use of the appropriate fivedigit CPT code and listed separately. 2. Reimbursement for the primary surgery or most significant procedure is reported first and shall be: a. According to guidelines in Section XII of this Manual; or b. An agreed upon contract price. 3. Reimbursement for the additional surgical procedure(s) shall be fifty percent (50%) of the ASC s billed charges, provided that reimbursement does not exceed the MRA for procedures listed in Section XVI, or the agreed upon contract price, or the MRA of the primary surgical procedure or most significant procedure. The additional surgical procedure(s) shall be listed separately and identified by appending modifier 51 to the appropriate five-digit CPT code. B. Reimbursement for Bilateral Procedures. 1. Reimbursement shall be made for bilateral procedures that are performed at the same operative session. 2. Reimbursement for a bilateral procedure that includes the word bilateral in the CPT descriptor shall be: a. According to guidelines in Section XII of this Manual; or b. An agreed upon contract price. 3. Reimbursement for a bilateral procedure that does not include the word bilateral in the CPT descriptor shall be made when the procedure is billed twice as follows: a. Reimbursement for the first procedure shall be: 1. According to guidelines in Section XII of this Manual; or 2. An agreed upon contract price. b. Reimbursement for the second procedure shall be fifty percent (50%) of the ASC s billed charges, provided that reimbursement does not exceed the MRA for procedures listed in Section XVI, or an agreed 9

13 upon contract price. The second procedure shall be listed separately and identified by appending modifier 50 to the five-digit procedure code. 4. When a procedure is performed unilaterally and the code descriptor is bilateral, the service shall be identified with modifier 52 and reimbursed according to documentation to explain the reduction in service. SECTION XIV: TERMINATED PROCEDURES A. A claim submitted for reimbursement of a terminated surgery must include a medical record that specifies the following: 1. Reason for termination of surgery; 2. Services actually performed; 3. Supplies actually provided; and 4. CPT code(s) for the procedure(s) had the surgery been performed. B. Terminated procedures shall be reimbursed as follows: 1. No payment shall be allowed for a procedure that is terminated either for medical or non-medical reasons before pre-operative procedures are initiated by staff. For example, payment is disallowed if scheduled surgery is canceled or postponed because patient on intake complains of a cold or flu. 2. Payment shall be fifty percent (50%) of the amount allowed for the procedure under Section XII, A or B, if a procedure is terminated due to the onset of medical complications after the patient has been prepared for surgery and taken to the operating suite, but before anesthesia has been induced. For example, fifty percent (50%) of the amount allowed is paid if the patient develops an allergic reaction to a drug administered by the staff prior to surgery. Such procedures shall be billed using CPT code modifier 73 (Discontinued Out-Patient Procedure Prior to Anesthesia Administration). 3. Payment shall be one-hundred percent (100%) of the amount allowed for the procedure under Section XII, A or B, if a medical complication arises which causes the procedure to be terminated after induction of the anesthetic agent. For example, the insurer shall make full payment if, after anesthesia has been accomplished and the surgeon has made a preliminary incision, the patient s blood pressure increases suddenly and the surgery is terminated to avoid increasing surgical risk to the patient. Such procedures shall be billed using CPT code modifier 72 (Discontinued Out-Patient Procedure After Anesthesia Administration). 10

14 SECTION XV: CHARGE MASTER AND MEDICAL RECORD REVIEW OR AUDIT A. The ASC shall produce, or make the documents available for on-site review, relevant portions of the ASC s Charge Master and any and all applicable medical records when requested by the Division, the Agency or by an insurer, or its designee, as part of an on-site audit to verify accuracy of the ASC s charges, billing practices, or medical necessity and compensability of charges for medical services and supplies. B. The ASC shall produce, or make available for on-site review, relevant portions of the ASC s Charge Master as required pursuant to negotiations between the ASC and the insurer or its designee regarding a proposed agreement for reimbursement for ASC services and/or supplies. C. The ASC shall produce copies of requested documents, or make the documents available for on-site review, within thirty (30) days of receipt of the written request from the Division, the Agency or an insurer, or its designee, to conduct a review or audit under this Section. D. When the ASC produces copies of requested documents, the insurer, or its designee, shall reimburse the ASC for copying charges pursuant to s F.S. E. When the ASC makes documents available for review, the insurer, or its designee, shall not be charged for the review. F. The ASC shall provide medical record(s) and Charge Master(s) to the Division or the Agency without charge. G. At the conclusion of an on-site review of documentation, an exit interview concerning the insurer s findings shall be conducted by the insurer, or its designee, if requested by the ASC. H. Neither a request nor completion of an on-site record review or audit shall toll the time frame for petitioning the Agency for resolution of a reimbursement dispute pursuant to s (7), F.S. 11

15 SECTION XVI: LISTED SCHEDULE OF MAXIMUM REIMBURSEMENT ALLOWANCES CPT MRA $1, $1, $ $3, $3, $3, $3, $3, $3, $5, $1, $ $1, $1, $1, $ $ $ $1, $1, $ $ $1, $1, $1, $1, $2,159 CPT only copyright 2006 American Medical Association. All Rights Reserved. 12

16 SECTION XVII: DISALLOWED, DENIED AND DISPUTED CHARGES A. Reimbursement for Services Unrelated to the Compensable Injury. The insurer shall not reimburse ASC charges for services unrelated to the treatment or care of a compensable injury. B. Physician Services. The insurer shall not reimburse an ASC for physician services when billed by the ASC on the ASC billing form. Proper billing and reimbursement of physician services rendered in any location, including inside an ASC shall be in accordance with the requirements of rules 69L and 69L-7.020, F.A.C. C. Disallowance and Adjustment of Itemized Charges. The insurer shall disallow reimbursement for any charges that are not documented in the patient s medical record, are not consistent with the ASC s Charge Master, or are for services, treatment or supplies that are not medically necessary for treatment of the patient s compensable injury or condition. D. Timely Payment and Notice of Adjustment, Disallowance or Denial. Notwithstanding the insurer s right to disallow charges, the insurer shall comply with the Florida Workers Compensation Medical Services Billing and Reporting Rule, rule 69L-7.602, and s (2)(b), F.S., that require timely payment, adjustment, disallowance or denial of an ASC bill. E. Minimum Partial Payment Required. At any time when an insurer denies, disallows or adjusts payment for ASC charges in accordance with the time limitations and coding requirements established by rule 69L-7.602, F.A.C., and s (2)(b), F.S., the insurer shall remit a minimum partial payment of the ASC's charges, which payment shall accompany the Explanation of Bill Review (EOBR). The minimum partial payment required shall include the applicable reimbursement for each of the itemized charges that are not denied, disallowed or disputed. Upon receipt of a minimum partial payment from the insurer, the ASC may elect to contest the disallowance or adjustment pursuant to s (7), F.S. 13

17 APPENDIX A MODIFIERS 14

18 APPENDIX A: MODIFIERS Modifiers change the basic services reported and identifies a procedure or service that has changed due to circumstances. CPT modifiers are 2-digit numeric and/or alphanumeric. Some modifiers impact reimbursement while others are for informational purposes and do not guarantee reimbursement. In some situations, it may be necessary for the ASC facility to submit a report with the bill to explain the circumstances in order for an insurer to determine payment. CPT Modifiers Description 22 Unusual Procedural Services 50 Bilateral Procedures 51 Multiple Procedures 52 Reduced Services 73 Discontinued Out-Patient Procedure Prior to Anesthesia Administration 74 Discontinued Out-Patient Procedure After Anesthesia Administration IM DI SH Surgical Implant Disposable Instrumentation Shipping and Handling CPT only copyright 2006 American Medical Association. All Rights Reserved. 15

19 APPENDIX B DEFINITIONS 16

20 APPENDIX B: DEFINITIONS 1. Agency means the Agency for Health Care Administration as defined in s (3), F.S. 2. Ambulatory Surgical Center (ASC) means a health care facility as defined in s (3), F.S. 3. Charge Master means a listing of the gross charge for each CPT procedure for which an ASC maintains a separate charge, with the ASC s gross charge for each CPT procedure, regardless of payer type. The charge master shall be maintained and produced when requested for the purpose of verifying its usual charges pursuant to Section (12)(d),F.S. 4. Authorization means the approval given to a health care provider by the insurer or self-insured employer for the provision of medical services to an employee. 5. Division means the Division of Workers Compensation of the Department of Financial Services as defined in s (14), F.S. 6. Emergency Services and Care means emergency services and care as defined in s , F.S. 7. Health Care Facility means a facility as defined in s (1), F.S. 8. Health Care Provider means a provider as defined in s (1), F.S. 9. Maximum Reimbursement Allowance (MRA) means the specifically listed maximum dollar amount in the schedule adopted by the three-member panel for reimbursement of medical service(s) rendered to an injured employee by a health care provider. 10. Medically Necessary or Medical Necessity means any medical service or medical supply which meets the definition of the terms according to s (1)(l), F.S. 11. Medical Record means the medical file that contains information that identifies the patient, supports the diagnosis, justifies the treatment and documents the care provided as required under Chapter 395, F.S. 12. Physician means a physician as defined in s (1)(q) F.S. 13. Surgical Implant means, for the purpose of determining reimbursement according to this manual, any single-use item that is surgically inserted and deemed to be medically necessary by an authorized physician and which the physician does not specify to be removed in less than six weeks such as bone, cartilage, tendon or other anatomical material obtained from a source other than the patient; plates; screws; pins; internal fixators; joint replacements; anchors; permanent neurostimulators; and pain pumps. Any single-use item that is surgically inserted into the body, to be removed in less than six weeks, or any single-use item connected for the purpose of giving effect or function to an item that is inserted into the body during 17

21 a surgical procedure such as ports, single-use temporary pain pumps, external fixators and temporary neurostimulators shall be considered associated disposable instrumentation. Associated disposable instrumentation does not include catheters removed prior to discharge, sutures, surgical staples, and drainage catheters. 18

22 APPENDIX C RULE 69L-7.100, FLORIDA ADMINISTRATIVE CODE 19

23 69L FLORIDA WORKERS COMPENSATION REIMBURSEMENT MANUAL FOR AMBULATORY SURGICAL CENTERS (ASCS) (1) The Florida Workers Compensation Reimbursement Manual for Ambulatory Surgical Centers, 2006 Edition, (ASC Reimbursement Manual) is incorporated by reference as part of this rule. The ASC Reimbursement Manual contains the Maximum Reimbursement Allowances (MRA) determined by the Three-Member Panel, pursuant to section (12), Florida Statutes and establishes reimbursement policies, guidelines, codes and maximum reimbursement allowances (MRAs) for items and services provided to an injured worker in connection with a surgical procedure performed in an Ambulatory Surgical Center. The ASC Reimbursement Manual is available for inspection during normal business hours at the Florida Department of Financial Services, Document Processing Section, 200 East Gaines Street, Tallahassee, Florida , or via the Department s web site at (2) The ASC Reimbursement Manual refers to a number of procedure codes and modifiers that are consistent with the Current Procedural Terminology (CPT ), developed and published by the American Medical Association. When a service or procedure is performed that does not have a code listed in the ASC Reimbursement Manual, the Ambulatory Surgical Center shall refer to the Current Procedural Terminology (CPT ), 2007 Professional Edition, Copyright 2006, American Medical Association, which is hereby incorporated by reference as part of this rule. (3) The Current Dental Terminology (CDT-2007/2008), Copyright 2006, American Dental Association, and the Healthcare Common Procedure Coding System (HCPCS) 2007, Nineteenth Edition, Copyright 2006, Ingenix Publishing Group, are incorporated by reference as part of this rule, for dental D codes, injectable J codes, and other medical services or supply codes as specified in the ASC Reimbursement Manual. (4) The Florida Workers Compensation Health Care Provider Reimbursement Manual, 2006, incorporated by reference into rule 69L-7.020, F.A.C., is also incorporated by reference into this rule. The Florida Workers Compensation Health Care Provider Reimbursement Manual, 2006, is available for inspection during normal business hours at the Florida Department of Financial Services, Document Processing Section, 200 East Gaines Street, Tallahassee, Florida , or via the Department s web site at Specific Authority (4), (14), FS. Law Implemented (7), (12), (14) FS. History New , Amended , Formerly 38F-7.100, 4L-7.100, Amended , Amended

24 INDEX 21

25 A Agency 17 Ambulatory Surgical Center 17 (ASC) Applicability 1 Authorization 1 ASC Facility Services 5 ASC Facilities 1 Florida 1 Out-of-State 1 Audits 3,8,11 B Billing 7,10 Bilateral Procedures 9,10 Modifier-50 9,10,15 Modifier-52 9,10,15 C Charge Master 4,11,13,17 Copying Charges 2, 3 Agency 3 Division 3 Injured Employee 2 Employer/Insurer 3 Judges 3 D Definitions (Appendix B) 16 Denied Charges 13 Disallowed Charges 13 Disputed Charges 13 Division 17 E Emergency Services and Care 1,17 F Facility Fee 4 Freestanding ASC 1 I Imaging Services 6,7 ASC 6,7 Outside 6 Implants 4,5,7,8 Modifier-IM 15 Modifier-DI 15 Modifier-SH 15 Independent ASC 1 L Laboratory Services 6 ASC 6 Outside 5, 6 M Managed Care 2 Maximum reimbursement allowance(mra) 1,6,7,9,10,12,17,19 Medically Necessary 17 Medical Necessity 17 Medical Record 2, 3,11,17 Medical Record Review 11 Modifiers ii,2,4,5,7 10,15,17,19 Multiple Procedures 9 Modifier-51 9,15 N Non-ASC Facility Services 5,6 O Out-of-State ASCs 1, 3 P Pathology Services 6 ASC 6 Outside 6 Physician 17 Professional Fee 4 H Health Care Facility 17 Health Care Provider 17 22

26 R Radiology Services 6,7 ASC 6,7 Outside 6 Reduced Services 10,15 Modifier References 2 Reimbursement and Utilization Disputes 11,13 Reimbursement Methodology 7 10 S Statutory Requirements 1 Surgical Implants 4,5,7,8,17 Modifier-IM 15 Modifier-DI 15 Modifier-SH 15 T Terminated Procedures 10 Details of Medical Record 10 Reimbursement 10 Modifier-72 10, 15 Modifier-73 10, 15 U Unusual Procedural Services 15 W Web Site (Florida Department of Financial Services) 19 23