Mich. Admin. Code R. 418.10904 - Procedure codes and modifiers
Rule 904.
(1) A
healthcare service must be billed with procedure codes adopted from "Current
Procedural Terminology (CPT) 2023 Professional Edition" or "HCPCS 2023 Level II
Professional Edition," as referenced in
R 418.10107. Procedure codes from
the CPT code set are not included in these rules, but are provided on the
agency's website at www.michigan.gov/leo/bureaus-agencies/wdca.
Refer to "Current Procedural Terminology (CPT) 2023 Professional Edition," as
referenced in R 418.10107,
for standard billing instructions, except where otherwise noted in these rules.
A provider billing services described with procedure codes from "HCPCS 2023
Level II Professional Edition" shall refer to the publication as adopted by
reference in R 418.10107,
for coding information.
(2) The
following ancillary service providers shall bill codes from "HCPCS 2023 Level
II Professional Edition," as adopted by reference in
R 418.10107, to describe the
ancillary services:
(a) Ambulance
providers.
(b) Certified orthotists
and prosthetists.
(c) Medical
suppliers, including expendable and durable equipment.
(d) Hearing aid vendors and suppliers of
prosthetic eye equipment.
(e) A
home health agency.
(3)
If a practitioner performs a procedure that cannot be described by 1 of the
codes listed in the most recent publication entitled "Current Procedural
Terminology (CPT)" or "HCPCS Level II", as adopted in
R 418.10107, the practitioner shall
bill the unlisted procedure code. An unlisted procedure code must only be
reimbursed when the service cannot be properly described with a listed code and
the documentation supporting medical necessity includes all of the following:
(a) Description of the service.
(b) Documentation of the time, effort, and
equipment necessary to provide the care.
(c) Complexity of symptoms.
(d) Pertinent physical findings.
(e) Diagnosis.
(f) Treatment plan.
(4) The provider shall add a modifier code,
found in Appendix A of the CPT codebook, as adopted by reference in
R 418.10107, following the correct
procedure code describing unusual circumstances arising in the treatment of a
covered injury or illness. When a modifier code is applied to describe a
procedure, a report describing the unusual circumstances must be included with
the charges submitted to the carrier.
(5) Applicable modifiers from table 10904
must be added to the procedure code to describe the type of practitioner
performing the service. The required modifier codes for describing the
practitioner are, as follows:
Table 10904 Modifier Codes
(a) AA: When anesthesia services are
performed personally by the anesthesiologist.
(b) AD: When an anesthesiologist provides
medical supervision for more than 4 qualified individuals, being either
certified registered nurse anesthetists, certified anesthesiologist assistants,
or anesthesiology residents.
(c)
AH: When a licensed psychologist bills a diagnostic service or a therapeutic
service, or both.
(d) AJ: When a
certified social worker bills a therapeutic service.
(e) AL: When a limited license psychologist
bills a diagnostic service or a therapeutic service.
(f) CO: When occupational therapy services
are furnished in whole or in part by an occupational therapy
assistant.
(g) CQ: When physical
therapy services are furnished in whole or in part by a physical therapy
assistant.
(h) CS: When a limited
licensed counselor bills for a therapeutic service.
(i) GF: When a non-physician (nurse
practitioner, advanced practice nurse, or physician assistant) provides
services.
(j) LC: When a licensed
professional counselor performs a therapeutic service.
(k) MF: When a licensed marriage and family
therapist performs a therapeutic service.
(l) ML: When a limited licensed marriage and
family therapist performs a service.
(m) TC: When billing for the technical
component of a radiology service.
(n) QK: When an anesthesiologist provides
medical direction for not more than 4 qualified individuals, being either
certified registered nurse anesthetists, certified anesthesiologist assistants,
or anesthesiology residents.
(o)
QX: When a certified registered nurse anesthetist or certified anesthesiologist
assistant performs a service under the medical direction of an
anesthesiologist.
(p) QZ: When a
certified registered nurse anesthetist performs anesthesia services without
medical direction.
Notes
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