Fla. Admin. Code Ann. R. 69L-7.730 - Health Care Provider Medical Billing and Reporting Responsibilities

(1) Bill Submission/Filing and Reporting Requirements.

(a) All health care providers are responsible for meeting their obligations, under this rule, regardless of any business arrangement with any entity under which claims are prepared, processed or submitted to the insurer.

(b) Each health care provider is responsible for submitting any form completion information and supporting documentation requested by the insurer that is in addition to the requirements of this rule and the applicable reimbursement manual, when it is requested, in writing, by the insurer at the time of authorization or upon receipt of notification of emergency care.

(c) Each health care provider shall resubmit a medical claim form or medical bill with insurer-requested documentation when the EOBR provides an explanation for the disallowed service based on the provider's failure to submit requested documentation with the medical bill.

(d) Insurers and health care providers shall utilize only the Form DFS-F5-DWC-25 for physician reporting of the injured employee's medical treatment/status. No other reporting forms may be used in lieu of or supplemental to the Form DFS-F5-DWC-25.

1. The Form DFS-F5-DWC-25 does not replace physician notes, medical records or Division-required medical reports.

2. All information submitted on physician notes, medical records or Division-required medical reports shall be consistent with information documented on the Form DFS-F5-DWC-25.

3. The DFS-F5-DWC-25, submitted to address the physical limitation(s), permanent impairment rating or maximum medical improvement date, shall be signed by the physician performing the physical examination upon which the physical limitation(s), permanent impairment or maximum medical improvement date is based.

(e) All medical claim form(s) or medical bill(s) related to authorized services shall be coded by the health care provider at the highest level of specificity for the reference material used and submitted to the claim administrator or any entity acting on behalf of the insurer, as a requirement for billing.

(f) Medical claim form(s) or medical bill(s) may be electronically filed or submitted via facsimile by a health care provider to the claim administrator or any entity acting on behalf of the insurer, provided the insurer agrees.

(g) When requested by the claim administrator or any entity acting on behalf of the insurer, a health care provider shall send documentation that supports the medical necessity of the specific services rendered and any other required documentation pursuant to subsection 69L-7.730(2), F.A.C., and the applicable reimbursement manual.

(h) Each health care provider is responsible for correcting and resubmitting any billing forms returned by a claim administrator or any entity acting on behalf of the insurer pursuant to paragraph 69L-7.740(11)(g), F.A.C.

(i) Each hospital and ASC shall maintain its charge master and shall produce relevant portions when requested for the purpose of verifying its usual charges pursuant to Section 440.13(12)(d), F.S.

(j) A health care provider shall bill multiple services, rendered on the same date of service, on a contiguous bill; provided however, nothing herein shall prevent a physician from selling, assigning or otherwise factoring a claim for the provision of pharmacy related services to a third party billing entity.

(2) Special Billing Requirements.

(a) When anesthesia services are billed on a Form DFS-F5-DWC-9, completion of the form shall include the CPT^® code and the "P" code (physical status modifier) that correspond with the procedure performed in Field 24D. Anesthesia health care providers shall enter the date of service and the 5-digit qualifying circumstance code that corresponds with the procedure performed in Field 24D on the next line, if applicable.

(b) When a Certified Registered Nurse Anesthetist (CRNA) provides anesthesia services, the CRNA shall bill on a Form DFS-F5-DWC-9 for the services rendered and enter his/her Florida Department of Health ARNP license number in Field 33b, regardless of the employment arrangement under which the services were rendered, or the identity of the party submitting the bill.

(c) Recognized practitioners, except physician assistants, ARNPs and CRNAs, who are salaried employees of an authorized treating physician and who render direct billable services for which reimbursement is sought from a claim administrator or any entity acting on behalf of the claim administrator, shall report and bill for such services on a Form DFS-F5-DWC-9 under the employing physician's name and license number.

(d) For hospital billing, the following special requirements apply:

1. Inpatient billing - Hospitals shall, in addition to filing a Form DFS-F5-DWC-90:

a. Attach an itemized statement with charges based on the facility's charge master; and,

b. Submit all specifically requested and additional documentation requested at the time of authorization; and,

c. Bill professional services provided by a physician, physician assistant, advanced registered nurse practitioner, or registered nurse first assistant on the Form DFS-F5-DWC-9, regardless of employment arrangement; and,

d. In Form Locator 80 - "Remarks"- make written entry "implant(s)" followed by the certification of the reimbursement amount calculated pursuant to Rule 69L-7.501, F.A.C.

2. Outpatient billing - Hospitals shall, in addition to filing a Form DFS-F5-DWC-90:

a. Enter the CPT^®, HCPCS or workers' compensation unique code and the applicable CPT^® or HCPCS modifier code in Form Locator 44 on the Form DFS-F5-DWC-90, when required pursuant to the UB-04 Manual; and,

b. Make written entry "scheduled" or "non-scheduled" in Form Locator 80 of Form DFS-F5-DWC-90 - "Remarks" on the DFS-F5-DWC-90 when billing outpatient surgery or outpatient surgical services; and,

c. Attach an itemized statement with charges based on the facility's charge master; and,

d. Submit all applicable documentation required pursuant to Rule 69L-7.501, F.A.C.; and,

e. Bill professional services provided by a physician or recognized practitioner on the Form DFS-F5-DWC-9, regardless of employment arrangement.

(e) A certified, licensed physician assistant, or registered nurse first assistant who provides services as a surgical assistant in lieu of a second physician, shall bill on a Form DFS-F5-DWC-9, entering the CPT^® code(s) plus modifier(s) representing the service(s) rendered in Field 24D, and shall enter his/her Florida Department of Health license number in Field 33b.

(f) Ambulatory Surgical Centers (ASCs) shall bill as follows:

1. For dates of service up to and including 07/07/2010, ASCs shall bill on Form DFS-F5-DWC-9 using the American Medical Association's CPT^® procedure codes or the workers' compensation unique procedure code 99070 with required modifiers, and shall bill charges based on the ASC's Charge Master, except when billing for procedure code 99070.

2. For dates of service on and after 07/08/2010, ASCs shall bill on Form DFS-F5-DWC-90 and shall enter the CPT^®, HCPCS, or workers' compensation unique code and the applicable CPT^® or HCPCS modifier code in Form Locator 44 for each service rendered. ASCs shall bill charges based on the ASC's charge master except when billing for surgical implants, associated disposable instrumentation and applicable shipping and handling. ASCs shall use revenue center code 0278 and workers' compensation unique code(s) with required modifier(s), as defined in the MEIG and pursuant to Rule 69L-7.100, F.A.C., when billing for surgical implants, associated disposable instrumentation, and applicable shipping and handling pursuant to Rule 69L-7.100, F.A.C. ASC medical bills shall be accompanied by all applicable documentation or certification required pursuant to Rule 69L-7.100, F.A.C.

(g) HHAs shall bill on Form DFS-F5-DWC-90.

1. For dates of service up to and including 07/07/2010, HHAs shall bill on letterhead or invoice.

2. For dates of service on or after 07/08/2010, HHAs shall bill on Form DFS-F5-DWC-90 and shall enter the CPT^®, HCPCS or workers' compensation unique codes and the applicable CPT^® or HCPCS modifier code in Form Locator 44 for each service rendered.

(h) Nursing home facilities shall bill on Form DFS-F5-DWC-90.

1. For dates of service up to and including 07/07/2010, nursing home facilities shall bill on letterhead or invoice.

2. For dates of service on or after 07/08/2010, nursing home facilities shall bill on Form DFS-F5-DWC-90 and shall enter the CPT^®, HCPCS or workers' compensation unique code and the applicable CPT^® or HCPCS modifier code in Form Locator 44 for each service rendered.

(i) Federal facilities shall bill on their usual form.

(j) Out-of-state health care providers shall bill on the applicable medical bill form pursuant to subsection 69L-7.730(3), F.A.C.

(k) Dental services.

1. Dentists shall bill for services on Form DFS-F5-DWC-11.

2. Oral surgeons shall bill for oral and maxillofacial surgical services on a Form DFS-F5-DWC-9. Non-surgical dental services shall be billed on Form DFS-F5-DWC-11.

(l) Pharmaceutical(s), Durable Medical Equipment and Home Medical Equipment or Supplies.

1. When dispensing commercially available medicinal drugs commonly known as legend or prescription drugs:

a. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the 11 digit original manufacturer's NDC number in Field 9a. When the dispensed drug is a repackaged/relabeled drug, the provider shall, in addition to the above, enter the repackaged NDC number in Field 9b of Form DFS-F5-DWC-10.

b. Physicians (including oral surgeons), physician assistants, ARNPs, and any other recognized practitioners registered to dispense medications pursuant to Section 465.0276, F.S., may dispense medications to the injured worker. Medication is treatment and must be authorized prior to dispensing, pursuant to Section 440.13(3)(a), F.S., and must be medically necessary to treat the compensable injury. Dispensing such medication may not be denied, absent a contrary contractual provision, and reimbursement may not be disallowed or adjusted for the sole reason that the injured worker has chosen to receive such medication from a practitioner registered to dispense medications under Chapter 465, F.S. All requests for authorization of medications to be dispensed must specify drug name, dosage, and strength, must be documented in the injured worker's file, and must be sent in a manner prescribed by the carrier pursuant to Section 440.13(3)(e), F.S. A carrier's failure to timely respond to a written request for authorization shall be governed by Section 440.13(3)(d), F.S.

c. Physicians (including oral surgeons), physician assistants, ARNPs, and any other recognized practitioner registered to dispense medications pursuant to Section 465.0276, F.S., shall bill on Form DFS-F5-DWC-9. Section 440.13(12)(c), F.S,, requires the Original Manufacturer's NDC Number to be included in the claim when repackaged or re-labeled medications have been dispensed. See the DFS-F5-DWC-9 Form Completion Instructions in Rule 69L-7.720, F.A.C.

d. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.

e. Dentists registered to dispense medications pursuant to Section 465.0276, F.S., shall bill on Form-DFS-F5-DWC-11. Section 440.13(12)(c), F.S., requires the Original Manufacturer's NDC Number to be included in the claim when repackaged or re-labeled medications have been dispensed. See the DFS-F5-DWC-11 Form Completion Instructions in Rule 69L-7.720, F.A.C.

2. When dispensing medicinal drugs which are compounded and the prescribed formulation is not commercially available:

a. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the workers' compensation unique code COMPD, as defined in the MEIG, in Field 9a.

b. Physicians, physician assistants or advanced registered nurse practitioners shall bill on Form DFS-F5-DWC-9 and shall enter the workers' compensation unique code COMPD, as defined in the MEIG, in Field 24D.

c. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.

3. When dispensing over-the-counter drug products:

a. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the 11 digit NDC number in form Field 9a.

b. Physicians (including oral surgeons), physician assistants and ARNPs shall bill on Form DFS-F5-DWC-9 and shall enter the 11 digit NDC number in the shaded portion above Field 24. See the DFS-F5-DWC-9 Form Completion Instructions in Rule 69L-7.720, F.A.C.

c. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.

4. When administering or dispensing injectable drugs:

a. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the 11 digit NDC number in Field 9a.

b. Physicians, physician assistants or ARNPs shall bill on a Form DFS-F5-DWC-9 and enter the appropriate HCPCS "J" code in form Field 24D. When an appropriate HCPCS "J" code is not available for the injectable drug, enter the 11 digit NDC number, preceded by the alpha-numeric qualifier (N4), in the shaded portion above Field 24. See the DFS-F5-DWC-9 Form Completion Instructions in Rule 69L-7.720, F.A.C.

c. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.

5. When dispensing DME:

a. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in Field 21 on Form DFS-F5-DWC-10.

b. Physicians and recognized practitioners shall bill on Form DFS-F5-DWC-9 and shall enter the applicable HCPCS code in Field 24D of the form and attach documentation indicating the actual cost of the supply.

c. Hospitals shall bill on Form DFS-F5-DWC-90 using the applicable revenue codes.

d. Home medical equipment providers shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in Field 21 on Form DFS-F5-DWC-10.

6. When dispensing medical supplies which are not incidental to a service or procedure:

a. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in Field 21 on Form DFS-F5-DWC-10.

b. Physicians and recognized practitioners shall bill on Form DFS-F5-DWC-9 and shall enter the applicable HCPCS code in Field 24D and attach documentation indicating the actual cost of the supply.

c. Hospitals shall bill on Form DFS-F5-DWC-90 under the applicable revenue codes.

d. Home medical equipment providers shall bill on Form DFS-F5-DWC-10 for DME supplies prescribed by a physician or recognized practitioner, and shall enter the applicable HCPCS code in Field 21 on Form DFS-F5-DWC-10.

7. Pharmacists who provide medication therapy management services shall bill for these services on Form DFS-F5-DWC-9 by entering the appropriate CPT^® code(s) that represent the service(s) rendered in form Field 24D, shall enter their Florida Department of Health license number in Field 33b and shall submit a copy of the physician's written prescription with the medical bill.

8. Pharmacists and medical suppliers may only bill on an alternate to Form DFS-F5-DWC-10 when an insurer has pre-approved use of the alternate form. Forms DFS-F5-DWC-9, DFS-F5-DWC-11 or DFS-F5-DWC-90 shall not be approved for use as the alternate form.

(m) Physicians billing for a failed appointment for a scheduled independent medical examination (when the injured employee does not report to the physician office as scheduled) shall bill worker's compensation unique code 99456-CN on the DFS-F5-DWC-9.

(n) Health care providers receiving reimbursement under any payment plan (pre-payment, prospective pay, capitation, etc.) shall accurately complete the Form DFS-F5-DWC-9 and submit the form to the insurer.

(o) Parties that are not physicians or recognized practitioners but are authorized by an insurer to render services reimbursable under workers' compensation shall bill on their invoice or letterhead. These parties shall not bill using Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11 or DFS-F5-DWC-90 as an invoice.

(p) Only a physician as defined in Section 440.13(1)(p), F.S., can bill workers' compensation unique codes 99455, 99456, 99457 when reporting services to address maximum medical improvement and permanent impairment.

(3) Bill Completion.

(a) Bills shall be legibly and accurately completed by all health care providers, regardless of location or reimbursement methodology, as set forth in this subpart and in subsection 69L-7.730(2), F.A.C.

(b) Billing elements required by the Division to be completed by a health care provider are identified in Form DFS-F5-DWC-9 completion instructions (Rev. 01/01/2015) available at the following websites:

1. http://www.myfloridacfo.com/Division/WC/provider/ Form DFS-F5-DWC-9-A Instructions Rev. 01/01/15, when submitted by Physicians and Recognized Practitioners;

2. http://www.myfloridacfo.com/Division/WC/provider/ Form DFS-F5-DWC-9-B Instructions Rev. 01/01/15, when submitted by Work Hardening and Pain Management Programs;

3. http://www.myfloridacfo.com/Division/WC/provider/ Form DFS-F5-DWC-9-C Instructions Rev. 01/01/15, when submitted by an ASC for dates of services before 07/08/2010.

(c) Billing elements required by the Division to be completed for Pharmaceutical or Medical Supplier Billing are identified in Form DFS-F5-DWC-10-A Completion Instructions, Rev. 12/22/2015, available at website: http://www.myfloridacfo.com/Division/WC/provider/ Form DFS-F5-DWC-10-A Instructions Rev. 12/22/15.

(d) Billing elements required by the Division to be completed for Dental Billing are identified in Form DFS-F5-DWC-11-A Completion Instructions, Rev. 01/01/2015, available at website: http://www.myfloridacfo.com/Division/WC/provider/ Form DFS-F5-DWC-11-A Instructions Rev. 01/01/15.

(e) Billing elements required by the Division to be completed by Facilities are identified in the Form DFS-F5-DWC-90 (UB-04) Completion Instructions, Rev. 01/01/15, available at the following websites:

1. http://www.myfloridacfo.com/Division/WC/provider/ Form DFS-F5-DWC-90-A Instructions Rev. 01/01/15, when submitted by a Hospital.

2. http://www.myfloridacfo.com/Division/WC/provider/ Form DFS-F5-DWC-90-B Instructions Rev. 01/01/15, when submitted by an Ambulatory Surgical Center for dates of services on or after 7/8/2010.

3. http://www.myfloridacfo.com/Division/WC/provider/ Form DFS-F5-DWC-90-C Instructions Rev. 01/01/15, when submitted by a Home Health Agency.

4. http://www.myfloridacfo.com/Division/WC/provider/ Form DFS-F5-DWC-90-D Instructions Rev. 01/01/15, when submitted by a Nursing Home Facility.

(f) A health care provider shall submit additional data elements or supporting documentation required for the adjudication of a bill upon receipt of a written request from the insurer/claim administrator pursuant to subsection 69L-7.740(2), F.A.C.

(g) A health care provider may bill consistent with the requirements of ICD-10 beginning on the implementation date specified for use of ICD-10 in Section 162.1002 of Title 45 of the Code of Federal Regulations. Under no circumstance may a health care provider utilize both ICD-9 and ICD-10 coding on the same bill.

Notes

Fla. Admin. Code Ann. R. 69L-7.730

Rulemaking Authority 440.13(4), (7), 440.15(3)(b), (d), 440.185(5), 440.20, 440.525(2), 440.591, 440.593(5) FS. Law Implemented 440.09, 440.13(2)(a), (3), (4), (6), (7), (11), (12), (14), (16), 440.15(3)(b), (d), (5), 440.185(5), (9), 440.20(6), 440.525(2), 440.593 FS.

Adopted by Florida Register Volume 42, Number 021, February 02, 2016 effective 2/18/2016, Amended by Florida Register Volume 49, Number 070, April 11, 2023 effective 4/11/2023.

Formerly 69L-7.710(4), F.A.C., Ratified by Ch. 2023-144, LOF.

New 2-18-16, 7-1-23.