Mich. Admin. Code R. 418.10901 - General information
Rule 901.
(1)
All health care practitioners and health care organizations, as defined in
these rules, shall submit charges on the proper claim form as specified in this
rule. Copies of the claim forms and instruction for completion for each form
shall be provided separate from these rules in a manual on the workers'
compensation agency's website at www.michigan.gov/wca. Charges shall be
submitted as follows:
(a) A practitioner shall
submit charges on the CMS1500 claim form.
(b) A doctor of dentistry shall submit
charges on a standard dental claim form approved by the American Dental
Association.
(c) A pharmacy, other
than an inpatient hospital, shall submit charges on an invoice or an NCPDP
Workers Compensation/Property & Casualty Universal Claim Form.
(d) A hospital-owned occupational or
industrial clinic, or office practice shall submit charges on the CMS 1500
claim form.
(e) A hospital billing
for a practitioner service shall submit charges on a CMS 1500 claim
form.
(f) Ancillary service charges
shall be submitted on the CMS 1500 claim form for durable medical equipment and
supplies, L-code procedures, ambulance, vision, and hearing services. Charges
for home health services shall be submitted on the UB-04 claim form.
(g) A shoe supplier or wig supplier shall
submit charges on an invoice.
(2) A provider shall submit all bills to the
carrier within 1 year of the date of service for consideration of payment,
except in cases of litigation or subrogation.
(3) A properly submitted bill shall include
all of the following appropriate documentation:
(a) A copy of the medical report for the
initial visit.
(b) An updated
progress report if treatment exceeds 60 days.
(c) A copy of the initial evaluation and a
progress report every 30 days of physical treatment, physical or occupational
therapy, or manipulation services.
(d) A copy of the operative report or office
report if billing surgical procedure codes 10021-69990.
(e) A copy of the anesthesia record if
billing anesthesia codes 00100-01999.
(f) A copy of the radiology report if
submitting a bill for a radiology service accompanied by modifier -26. The
carrier shall only reimburse the radiologist for the written report, or
professional component, upon receipt of a bill for the radiology
procedure.
(g) A report describing
the service if submitting a bill for a "by report" procedure.
(h) A copy of the medical report if a
modifier is applied to a procedure code to explain unusual billing
circumstances.
(4) A
health care professional billing for telemedicine services shall utilize
procedure codes 92507, 92521-92524, 97110, 97112, 97116, 97161-97168, 97530,
97535 or those listed in Appendix P of the CPT codebook, as adopted by
reference in
R 418.10107, excluding CPT codes
99241-99245 and 99251-99255. The provider shall append modifier -95 to the
procedure code to indicate synchronous telemedicine services rendered via a
real-time interactive audio and video telecommunications system with place of
service code -02. All other applicable modifiers shall be appended in addition
to modifier -95.
Notes
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