Return to Billing & Payment Policies

 

Facility Services -

Brain Injury Rehabilitation Services

Billing for Separate Services and Therapies

Brain injury and rehabilitation services are currently under review. Until that review is complete and upon approval by an ONC, individual services and therapies can be done separately through outpatient services when the provider submits a coordinated plan of care. Services can include but are not limited to:

• Psychotherapy services
• Speech therapy
• Medical services
• Neural therapy
• Occupational therapy

Qualified Providers

Only providers approved by the insurer can provide post-acute brain injury rehabilitation services for workers. When a complete course of evaluation and treatment is required, L&I requires providers treating a patient on a State Fund claim to submit that plan to

Department of Labor & Industries
Provider Accounts Unit
PO Box 44261
Olympia, WA 98504-4261

Special L&I Provider Account Number Required

Providers participating in the Brain Injury Program must have a special provider account number if they have CARF accreditation to treat and bill for a complete course of evaluation and treatment. Providers may request a provider application or find out if they have a qualifying provider account number by calling the Provider Hotline at 800-848-0811.

NOTE: Billing for State Fund claims: Providers participating in the Brain Injury Program must bill brain injury rehabilitation services using the special post-acute brain injury rehabilitation program provider account number assigned by L&I. Providers billing for individual services and therapies do not need to obtain a special provider account number.

QUALIFYING PROGRAMS

Post-acute brain injury rehabilitation programs must include the following phases:

• Evaluation
• Treatment
• Follow-up

AUTHORIZATION REQUIREMENTS

Prior authorization is required for post-acute brain injury rehabilitation evaluation and treatment. For State Fund claims, cases requiring post-acute brain injury rehabilitation will be reviewed by the ONCs prior to making a determination or authorization. Call the Provider Hotline at 800-848-0811 for authorization.

After an ONC reviews the case the L&I claims manager also needs to review for prior authorization.

For self-insured claims, contact the SIE/TPA for authorization.
http://www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp

Approval Criteria

Before a worker can receive treatment all of the following conditions must be met:

• The insurer has allowed brain injury as an accepted condition under the claim; and
• The brain injury is related to the industrial injury or is retarding recovery; and
• The worker is physically, emotionally, cognitively and psychologically capable of full participation in the rehabilitation program; and
• The screening evaluation done by the brain injury program demonstrates the worker is capable of new learning following the brain injury; and
• The screening evaluation report by the program identifies specific goals to help the worker improve function or accommodate for lost function.

Comprehensive Brain Injury Evaluation Requirements

A Comprehensive Brain Injury Evaluation must be performed for all workers who are being considered for inpatient services or for an outpatient post-acute brain injury rehabilitation treatment program. This evaluation is multidisciplinary and contains an in-depth analysis of the workers mental, emotional, social and physical status and functioning.

The evaluation must be provided by a multidisciplinary team that includes a

• Medical physician,
• Psychologist,
• Vocational rehabilitation specialist,
• Physical therapist,
• Occupational therapist,
• Speech therapist and
• Neuropsychologist.

Additional medical consultations are referred through the program‘s physician. For State Fund claims, each consultation may be billed under the provider account number of the consulting physician. Services must be preauthorized by an L&I claim manager or the self-insured employer.

BILLING INFORMATION

Tests Included in the Comprehensive Brain Injury Program Evaluation

The following tests and services are included in the price of performing a Comprehensive Brain Injury Program Evaluation and may not be billed separately. They may be performed in any combination depending on the workers condition

• Neuropsychological Diagnostic Interview(s), testing and scoring
• Initial consultation and exam with the program‘s physician
• Occupational and Physical Therapy evaluations
• Vocational Rehabilitation evaluation
• Speech and language evaluation
• Comprehensive report

Preparatory Work Included in the Comprehensive Brain Injury Program Evaluation

The complementary and/or preparatory work that may be necessary to complete the Comprehensive Brain Injury Evaluation is considered part of the provider‘s administrative overhead. It includes but is not limited to:

• Obtaining and reviewing the workers historical medical records
• Interviewing family members, if applicable
• Phone contact and letters to other providers or community support services
• Writing the final report
• Office supplies and materials required for service(s) delivery

Therapies Included in the Treatment

The following therapies, treatments and/or services are included in the Brain Injury Program maximum fee schedule amount for the full-day or half-day brain injury rehabilitation treatment and may not be billed separately:

• Physical therapy and occupational therapy
• Speech and language therapy
• Psychotherapy
• Behavioral modification and counseling
• Nursing and health education and pharmacology management
• Group therapy counseling
• Activities of daily living management
• Recreational therapy (including group outings)
• Vocational counseling
• Follow-up interviews with the worker or family, which may include home visits and phone contacts

Preparatory Work Included in Treatment

Ancillary work, materials and preparation that may be necessary to carry out Brain Injury Program functions and services that are considered part of the provider‘s administrative overhead and are not payable separately include, but are not limited to:

• Daily charting of patient progress and attendance
• Report preparation
• Case management services
• Coordination of care
• Team conferences and interdisciplinary staffing
• Educational materials (for example, workbooks and tapes)

Follow Up Included in Treatment

Follow up care is included in the cost of the full day or half day program. This includes, but is not limited to:

• Telephone calls
• Home visits
• Therapy assessments

DOCUMENTATION REQUIREMENTS

The following documentation is required of providers when billing for post-acute brain injury rehabilitation treatment programs:

• Providers are required to keep a daily record of a workers attendance, activities, treatments and progress
• All test results and scoring must also be kept in the workers medical record. Records should also include:
  • Documentation of interviews with family and
  • Any coordination of care contacts (for example, phone calls and letters) made with providers or case managers not directly associated with the facility‘s program
• Progress reports should be sent to the insurer regularly, including all preadmission and discharge reports

FEES

Non-Hospital Based Programs

The following local codes and payment amounts for nonhospital based outpatient post-acute brain injury rehabilitation treatment programs are effective July 1, 2010.

Code	Description	Maximum Fee
8950H	Comprehensive brain injury evaluation	$4,297.53
8951H	Post-acute brain injury rehabilitation full-day program, per day (minimum of 6 hours per day)	$974.87
8952H	Post-acute brain injury rehabilitation half-day program, per day (minimum 4 hours per day)	$678.97

Hospital Based Programs

The following revenue codes and payment amounts for hospital based outpatient post-acute brain injury rehabilitation treatment programs are effective July 1, 2010.

Code	Description	Maximum Fee
0014	Comprehensive brain injury evaluation	$4,297.53
0015	Post-acute brain injury rehabilitation full-day program, per day (minimum of 6 hours per day)	$974.87
0016	Post-acute brain injury rehabilitation half-day program, per day (minimum 4 hours per day)	$678.97