Subpart
1.
Usual charges.
No provider shall submit a charge for a service that exceeds
the amount that the provider charges for the same type of service in cases
unrelated to workers' compensation injuries.
Subp. 1a.
Conflicts of interest.
All health care providers subject to this chapter are bound by
the federal Medicare antikickback statute in section 1128B(b) of the Social
Security Act, United States Code, title 42, section 1320a-7b(b), and
regulations adopted under it, pursuant to Minnesota Statutes, section
62J.23.
Any medical services or supplies provided in violation of these provisions are
not compensable under Minnesota Statutes, chapter 176.
Subp. 2.
Submission of
information.
Providers except for hospitals must supply with the bill a copy
of an appropriate record that adequately documents the service and
substantiates the nature and necessity of the service or charge. Hospitals must
submit an appropriate record upon request by the payer. All charges billed
after January 1, 1994, for workers' compensation health care services,
articles, and supplies, except for United States government facilities
rendering health care services for veterans, must be submitted to the payer in
the formats prescribed in subparts 2a, 2b, 2c, and 2d, and in accordance with
items A to C.
A. Charges for services,
articles, and supplies must be submitted to the payer directly by the health
care provider actually furnishing the service, article, or supply. This
includes but is not limited to the following:
(1) diagnostic imaging, laboratory, or
pathology testing not actually performed by the health care provider, or
employee of the health care provider, who ordered the test;
(2) equipment, supplies, and medication not
ordinarily kept in stock by the hospital or other health care provider
facility, purchased from a supplier for a specific employee;
(3) services performed by a health care
provider at a hospital, if the provider has an independent practice, except
that a hospital may charge for services furnished by a provider who receives at
least a base payment from the hospital, which is paid regardless of the number
of patients seen; and
(4)
outpatient medications dispensed by a licensed pharmacy pursuant to an order
written by a health care provider, as described in this subpart, including both
prescription and nonprescription medications.
B. Charges must be submitted to the payer in
the manner required by subparts 2a, 2b, 2c, and 2d, within 60 days from the
date the health care provider knew the condition being treated was claimed by
the employee as compensable under workers' compensation. Failure to submit
charges within the 60 days is not a basis to deny payment, but is a basis for
disciplinary action against the provider under Minnesota Statutes, section
176.103.
Failure to submit claims within the time frames specified in Minnesota
Statutes, section
62Q.75,
subdivision 3, may result in denial of payment.
C. This part does not limit the collection of
other information the provider may be required to report under any other state
or federal jurisdiction.
Subp.
2a.
ASC X12 Health Care Claim: Professional (837)
format.
Except as provided in subparts 2b , 2c, and 2d, charges for all
services, articles, and supplies that are provided for a claimed workers'
compensation injury must be submitted to the payer electronically in the ASC
X12 Health Care Claim: Professional (837) format required by Minnesota
Statutes, sections
62J.50 to
62J.61,
and the corresponding uniform companion guide adopted by the Department of
Health under Minnesota Statutes, sections
62J.536
and
62J.61.
Subp. 2b.
ASC X12 Health
Care Claim: Institutional (837) format.
A. Hospitals licensed under Minnesota
Statutes, section
144.50,
must submit charges electronically in the ASC X12 Health Care Claim:
Institutional (837) format required by Minnesota Statutes, sections
62J.50 to
62J.61,
and the corresponding uniform companion guide adopted by the Minnesota
Department of Health under Minnesota Statutes, sections
62J.536
and
62J.61.
B. When the billing format in item A provides
only summary information, an itemized listing of all services and supplies
provided during the inpatient hospitalization must be attached , except as
otherwise provided in Minnesota Statutes, section
176.1362.
The itemized list must include:
(1) where a
code is assigned to a service, the approved procedure codes and modifiers
appropriate for the service, in accordance with subpart 3. Charges for supplies
need not be coded, but a description and charge for specific articles and
supplies must be itemized;
(2) the
charge for each service;
(3) the
number of units of each service provided; and
(4) the date each service was
provided.
Subp.
2c.
Submission of drug charges.
A. Itemized charges for drugs dispensed for a
claimed workers' compensation injury by a licensed community/outpatient
pharmacy must be submitted to the payer electronically in the National Council
for Prescription Drug Programs (NCPDP) Version D, Release 0 format required by
Minnesota Statutes, sections
62J.50 to
62J.61,
and the corresponding uniform companion guide adopted by the Minnesota
Department of Health under Minnesota Statutes, sections
62J.536
and
62J.61.
B. Charges for drugs dispensed by a
practitioner as defined in Minnesota Statutes, section
151.01, subdivision
23, who is permitted to dispense drugs under Minnesota Statutes, chapter 151,
may be submitted to the payer according to the applicable requirements of this
subpart or subpart 2a.
C. Charges
for drugs dispensed by a hospital may be submitted according to the applicable
requirements of this subpart or subpart 2b.
D. The terms " community/outpatient
pharmacy," "dispense," "drug," "practitioner," and "usual and customary charge"
in this subpart have the meanings given to them in part 5221.4070, subpart
1a.
Subp. 2d.
ASC
X12 Health Care Claim: Dental (837) format.
Charges for dental services must be submitted to the payer
electronically in the ASC X12 Health Care Claim: Dental (837) format required
by Minnesota Statutes, sections
62J.50 to
62J.61,
and the corresponding uniform companion guide adopted by the Minnesota
Department of Health under Minnesota Statutes, sections
62J.536
and
62J.61.
Subp. 3.
Billing
code.
A. The provider shall undertake
professional judgment to assign the correct approved billing code, and any
applicable mod-ifiers, in the CPT, HCPCS, NDC, or UB-04 Data Specifications
manual in effect on the date the service, article, or supply was rendered,
using the appropriate provider group designation, and according to the
instructions and guidelines in this chapter. No provider may use a billing code
that is assigned a "D," "F," "G," or "H" status as described in part 5221.4020,
subpart 2a, item D. Where several component services which have different CPT
codes may be described in one more comprehensive CPT code, only the single CPT
code most accurately describing the procedure performed or service rendered may
be reported.
Dental procedures not included in CPT or HCPCS shall be coded
using the Code on Dental Procedures and Nomenclature (CDT code) as published by
the American Dental Association.
Inpatient services shall be coded using the same codes,
formats, and details that are required for billing for hospital inpatient
services by the Medicare program as required by Minnesota Statutes, section
176.1362,
subdivision 1, paragraph (c).
B. The codes for services in parts 5221.4030
to 5221.4070 may be submitted with two-digit or two-letter suffixes called
"modifiers" as defined in part 5221.0100, subpart 10a. Except as otherwise
specifically provided in parts 5221.4005 to 5221.4070, the use of a modifier
does not change the maximum fee to be calculated according to part
5221.4020.
C. Provider group
designation.
(1) General. The provision of
services by all health care providers is limited and governed by each
provider's scope of practice as stated in the applicable statute. A provider
shall not perform a service that is outside the provider's scope of practice,
nor shall a provider use a procedure code for a service that is outside the
provider's scope of practice. Services delivered at the direction and under the
supervision of a licensed health care provider listed in this item are
considered incident to the services of the licensed provider and are coded as
though provided directly by the licensed provider. Services delivered by
support staff such as aides, assistants, or other unlicensed providers are
incident to the services of a licensed provider only if the licensed provider
directly responsible for the unlicensed provider is on the premises at the time
the service is rendered. Hospital charges are governed by part 5221.0500,
subpart 2, items C and D.
(2)
Medical and surgical services. Procedure codes for medical and surgical
services and supplies are listed in part 5221.4030. These include services
delivered by the following types of providers or services provided incident to
the services of the following types of providers: medical physicians, surgeons,
osteopathic physicians, podiatrists, dentists, oral and maxillofacial surgeons,
optometrists, opticians, speech pathologists, licensed psychologists, social
workers, nurse practitioners, clinical nurse specialists, and physician
assistants.
(3) Pathology and
laboratory services. Procedure codes for services and supplies provided by a
pathologist or by a technician under the supervision of a physician are listed
in part 5221.4040.
(4) Physical
medicine and rehabilitation services. Procedure codes for services and supplies
provided by a physician, an osteopathic physician, a physical therapist, an
occupational therapist, a physical therapist assistant under the direction and
supervision of a physical therapist, or a certified occupational therapy
assistant under the direction and supervision of an occupational therapist, or
provided incident to the services of a physician, an osteopathic physician, a
physical therapist, or an occupational therapist are listed in part
5221.4050.
(5) Chiropractic
services. Procedure codes for services and supplies provided by a chiropractor
or provided incident to a chiropractor's services are listed in part
5221.4060.
(6) Pharmacy services.
Procedure codes for drugs dispensed pursuant to the order of a health care
provider, are described in part 5221.4070.
Subp. 4.
Cooperation with payer.
Pursuant to Minnesota Statutes, section
176.138,
providers shall comply within seven working days with payers' proper written
requests for copies of existing medical data concerning the services provided,
the patient's condition, the plan of treatment, and other issues pertaining to
the payer's determination of compensability or excessiveness.
Subp. 5. [Repealed, 18 SR 1472]
