Utah Admin. Code R612-300-5 - Fees for Specific Procedures
A.
Needle procedures: Trigger point injections are reported per muscle. Payment
under CPT code 20553 for injections of up to three muscles is the maximum
allowed for any one treatment session, regardless of the number of muscles
treated.
B. Radiology.
1. The cost of radioisotopes, gadolinium and
comparable materials may be charged at the provider's cost plus 15%.
2. When x-rays are reviewed as part of an
independent evaluation of the patient, a consultation, or other office visit,
the review is included as a part of the basic service to the patient and may
not be billed separately.
C. Restorative Services.
1. The following criteria must be met before
payment is allowed for restorative services:
a. The patient's condition must have the
potential for restoration of function;
b. The treatment must be prescribed by the
treating physician;
c. The
treatment must be specifically targeted to the patient's condition;
and
d. The provider must be in
constant attendance during the providing of treatment.
2. No payment is allowed for CPT codes 97024,
diathermy; 97026, infrared therapy; 97028, ultraviolet therapy/cold laser
therapy; 97169, athletic training evaluations; 97172, athletic training
reevaluation.
3. All restorative
services provided must be itemized even if not billed.
4. Medical providers billing under CPT codes
97010 through 97150, 97161 through 97168, and 97530 through 97610 are limited
to payment for a maximum of three procedures/units per visit, or six
procedures/units if more than one site is treated. Services billed under CPT
codes 97545, 97546 and 97150 require preauthorization and are limited to 4
units per injury. The payor shall pay the three highest valued procedures for
each treatment site/body part for the visit.
5. Patient education is to be billed using
CPT code 97535 rather than codes 98960 through 98962, is paid in addition to
the three highest valued procedures, and is limited to 4 units per injury
claim. Patient education includes training in activities of daily living,
lifestyle, and any restrictions to accommodate the patient's return to
work.
6. The entire spine is
considered to be a single body part or unit. For that reason, CPT codes 98941
through 98943 and 98926 through 98929 may not be used for billing
purposes.
7. When a change in
treatment or a new RSA is required, physicians and physical therapists may bill
for one evaluation and up to 2 modalities/procedures. Without an evaluation,
they may bill for up to 3 modalities/procedures. 97164 and 97168 may be used
for re-evaluation of the patient's condition. With prior authorization from the
payor, physicians and physical therapists may make additional billing when
justified by special circumstances. 97164 and 97168 shall not be used as an
office charge only. Documentation must reflect that a reevaluation was
necessary and performed due to complications, additional surgeries and/or
procedures, change in medical providers, or a change in stability of the
patient's condition. Generally, this should be used every six visits unless
there is objective documentation that a reevaluation and modification of
treatment was necessary.
8. Any
medical provider billing for restorative services shall file the appropriate
version of Form 221, "Restorative Services Authorization (RSA) form" with the
payor and the Division within ten days of the initial evaluation.
Subjective/objective/ assessment/plan ("SOAP") notes are to be sent to the
payor in addition to the RSA form. SOAP notes are not to be sent to the
Division unless requested.
a. Upon receipt of
the provider's RSA form and SOAP notes, the payor shall respond within business
ten days by authorizing a specified number of treatments or denying the
request. No more than eight treatments may be provided during this ten-day
authorization period. If the payor does not respond within ten business days
from the RSA submission date, any visits during that ten day period shall be
paid by the payor.
b. A payor may
deny the requested treatments for the following reasons:
i. The injury or disease being treated is not
work related; or
ii. The payor has
received written medical opinion or other medical information indicating the
treatment is not necessary. A copy of such written opinion or information must
be provided to the injured worker, the medical provider, and the
Division.
c. In cases
where approval is received for initial treatment, the provider shall submit
updated RSA forms and SOAP notes to the payor for approval or denial at least
every six treatments.
d. An injured
worker or provider may request a hearing before the Division of Adjudication to
resolve issues of compensability, necessity of treatment, and compliance with
this subsection's time limits.
D. Functional Capacity Evaluations. The
following functional capacity evaluations require payor preauthorization and
are billed in 15 minute increments under CPT code 97750:
1. A limited functional capacity evaluation
to determine an injured worker's dynamic maximal repetitive lifting, walking,
standing and sitting tolerance. Billing for this type of evaluation is limited
to a maximum of 45 minutes.
2. A
full functional capacity evaluation to determine an injured worker's maximum
and repetitive lifting, walking, standing, sitting, range of motion, predicted
maximal oxygen uptake, as well as ability to stoop, bend, crawl or perform work
in an overhead or bent position. In addition, this evaluation includes
reliability and validity measures concerning the individual's performance.
Billing for this type of evaluation is limited to a maximum of 2.5
hours.
3. A work capacity
evaluation to determine an injured worker's capabilities based on the physical
aspects of a specific job description. Billing for this type of evaluation is
limited to a maximum of 2 hours.
4.
A job analysis to determine the physical aspects of a particular job. Billing
is not subject to a maximum time limit due to the variability of factors
involved in the analysis.
E. Impairment Ratings and Insurance Medical
Examinations.
1. Impairment Rating by
Treating Physician. Treating physicians shall bill for preparation of
impairment ratings under CPT code 99455, with 2.0 RVU assigned/30
minutes.
2. Impairment Rating by
Non-Treating Physician. Non-treating physicians may bill for preparation of
impairment ratings under CPT code 99456, with 2.65 RVU assigned/30
minutes.
3. Medical Evaluations
Commissioned by Payors. The Labor Commission does not regulate fees for medical
evaluations requested by payors.
F. Transcutaneous Electrical Nerve Simulators
(TENS). No fee is allowed for TENS unless it is prescribed by a physician and
supported by prior diagnostic testing showing the efficacy of TENS in control
of the patient's chronic pain. TENS testing and training is limited to four (4)
sessions and a 30-day trial period but may be extended with written
documentation of medical necessity.
G. Electophysiologic Testing. A physician who
is legally authorized by his or her medical practice act to diagnose injury or
disease is entitled to the full fee for electrophysiologic testing. Physical
therapists and physicians who are qualified to perform such testing but who are
not legally authorized to diagnose injury or disease are entitled to payment of
75% of the full fee.
H. Dental
Injuries.
1. Initial Treatment.
a. If an employer maintains a medical staff
or designates a company doctor, an employee requiring treatment for a workplace
dental injury shall report to such medical staff or doctor and follow their
directions for obtaining the necessary dental treatment.
b. If an employer does not maintain a medical
staff or designate a company doctor, or if such medical staff or doctor is
unavailable, the injured worker may obtain the necessary dental care from a
dentist of his or her choice. The payor shall pay the dentist at 70% of UCR for
services rendered.
2.
Subsequent treatment.
a. If additional dental
care is necessary, the dentist who provided initial treatment may submit to the
payor a request for authorization to continue treatment. The transmission date
of the request must be verifiable. The request itself must include a
description of the injury, the additional treatment required, and the fee to be
charged for the additional treatment.
i. The
payor shall respond to the request for authorization within 10 working days of
the request's transmission. This 10-day period can be extended with written
approval of the Director of the Industrial Accidents Division.
ii. If the payor does not respond to the
dentist's request for authorization within 10 working days, the dentist may
proceed with treatment and the payor shall pay the cost of treatment as
contained in the request for authorization.
iii. If the payor approves the proposed
treatment, the payor shall send written authorization to the dentist and
injured worker. This authorization shall include the amount the payor agrees to
pay for the treatment. If the dentist accepts the payor's payment offer, the
dentist may proceed to provide the approved services and shall be paid the
agreed upon amount.
iv. If the
dentist proceeds with treatment without authorization, the dentist's fee is
limited to 70% of UCR.
b. If the dentist who provided initial
treatment is unwilling to provide subsequent treatment under the terms outlined
in subsection 2.a., above, the payor shall within 20 calendar days direct the
injured worker to a dentist located within a reasonable travel distance who
will accept the payor's payment offer.
i. If,
after receiving notice that the payor has arranged for the services of a
dentist, the injured worker chooses to obtain treatment from a different
dentist, the payor shall only be liable for payment at 70% of UCR. The treating
dentist may bill the injured worker for the difference between the dentist's
charges and the amount paid by the insurer.
c. If the payor is unable to locate another
dentist to provide the necessary services, the payor shall attempt to negotiate
a satisfactory reimbursement with the dentist who provided initial
treatment.
I.
Drug testing. Drug screenings for addictive classes of pain medications shall
be performed as recommended in the Utah clinical Guidelines on Prescribing
Opiates for Treatment of Pain, Utah Department of Health 2009. The collection
and billing shall be limited to one 80305, 80306, or 80307 code per date of
service, except for unusual circumstances.
Notes
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