Mich. Admin. Code R. 418.10106 - Procedure codes; relative value units; other billing information
Rule 106.
(1) Upon
annual promulgation of
R 418.10107, the health care
services division of the agency shall provide separate from these rules a
manual, tables, and charts containing all of the following information on the
agency's website, www.michigan.gov/leo/bureaus-agencies/wdca:
(a) All Current Procedural Terminology (CPT)
procedure codes used for billing healthcare services.
(b) Medicine, surgery, and radiology
procedures and their associated relative value units.
(c) Hospital maximum payment
ratios.
(d) Billing forms and
instruction for completion.
(2) The procedure codes and standard billing
and coding instructions for medicine, surgery, and radiology services are
adopted from the most recent publication titled "Current Procedural Terminology
(CPT)," as adopted by reference in
R 418.10107. However, billing and
coding guidelines published in the CPT codebook do not guarantee reimbursement.
A carrier shall only reimburse medical procedures for a work-related injury or
illness that are reasonable and necessary and are consistent with accepted
medical standards.
(3) The formula
and methodology for determining the relative value units is adopted from the
"Medicare RBRVS: The Physicians Guide," as adopted by reference in
R 418.10107, using geographical
information for this state. The geographical information, (GPCI), is a melded
average using 60% of the figures published for the city of Detroit, added to
40% of the figures published for the rest of this state.
(4) The maximum allowable payment for
medicine, surgery, and radiology services is determined by multiplying the
relative value unit assigned to the procedure by the conversion factor listed
in the reimbursement section, part 10, of these rules.
(5) Procedure codes from "HCPCS 2023 Level II
Professional Edition," as adopted by reference in
R 418.10107, must be used to
describe all of the following services:
(a)
Ambulance services.
(b) Medical and
surgical expendable supplies.
(c)
Dental procedures.
(d) Durable
medical equipment.
(e) Vision and
hearing services.
(f) Home health
services.
(6) Medical
services are considered "by report" (BR) if a procedure code listed in "HCPCS
2023 Level II Professional Edition" or "Current Procedural Terminology
(CPT®) 2023 Professional Edition," as adopted by reference in
R 418.10107, does not have an
assigned value.
Notes
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