Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims

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Effective July 1, 2012

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Table of contents

Definitions

Payment policies:
Botulinum toxin (BTX)
Compound drugs
Hyaluronic acid for osteoarthritis of the knee
Immunizations
Immunotherapy
Infusion therapy services and supplies for RBRVS providers
Injectable medications
Medical foods and co-packs
Non-injectable medications
Spinal Injections
Therapeutic or diagnostic injections

More info:
Related topics

 

Definitions

Bundled:

A bundled procedure code isn’t payable separately because its value is accounted for and included in the payment for other services.  Bundled codes are identified in the fee schedules.

Pharmacy and DME providers may bill for services that are bundled in the fee schedules for other provider types.  This is because, for these provider types, there isn’t an office visit or a procedure into which supplies can be bundled.  Coverage of these bundled services will depend on the department’s policies.

Link: For the legal definition of “bundled,” see WAC 296-20-01002 .

By report (BR):

A code listed in the fee schedule as “BR” doesn’t have an established fee because the service is too unusual, variable, or new.  When billing for the code, the provider must provide a report that defines or describes the services or procedures.  The insurer will determine an appropriate fee based on the report.

Link: For more information, see WAC 296-20-01002 .

CPT® and HCPCS code modifiers mentioned in this chapter:

Dry needling:

A technique where needles are inserted (no medications are injected) directly into trigger point locations as opposed to the distant points or meridians used in acupuncture.  Dry needling is considered a variant of trigger point injections with medications.

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Payment policy: Botulinum toxin (BTX)

Prior authorization

The insurer covers botulinum toxin injections (Botox®: BTX-A, Myobloc®: BTX-B), with prior authorization for the following indications when it is proper and necessary:

• Blepharospasm,
• Primary axillary hyperhidrosis,
• Cervical dystonia (spasmodic torticollis),
• Strabismus,
• Hemifacial spasm,
• Torsion dystonia (idiopathic/symptomatic),
• Laryngeal or spasmodic dysphonia,
• Torticollis, unspecified,
• Orofacial dyskinesia,
• Writer’s cramp, and
• Oromandibular dystonia.

Note: Patients must have failed conservative treatment such as other medications and physical therapy before Botox will be authorized.

To get an additional injection authorized:

• Providers must submit documents describing the patient’s response to BTX following a session of injections, and
• If the first BTX session produced an adequate, functional response, the insurer may authorize one subsequent injection session administered 90 days after the initial session.

Note: No more than two injections per individual will be authorized due to risk of antibody development and decrease in response.

Link: For more information, go to
              www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/botulinumtoxin.asp.

Requirements for billing

Billing codes

If the injection is…	Then the appropriate HCPCS billing code is:	Which has a maximum fee of:
Onabotulinumtoxin A, 1 unit (Botox® or Botox Cosmetic®)	J0585	$5.67
Abobotulinumtoxin A, 5 units (Dysport®)	J0586	$7.67
Rimabotulinumtoxin B, 100 units (Myobloc®)	J0587	$10.78
Incobotulinumtoxin A, 1 unit (Xeomin®)	J0588	$5.67

Services that aren’t covered

The insurer won’t authorize payment for BTX injections for other off label indications.

 

Payment policy: Compound drugs

Prior authorization

All compounded drug products require prior authorization.  Failure to seek authorization before compounding will risk non-payment of compounded products.

Compounded drug products include, but aren’t limited to:

• Antibiotics for intravenous therapy,
• Pain cocktails for opioid weaning, and
• Topical preparations containing multiple active ingredients or any non-commercially available preparations.

Link: For more information, see the department’s coverage policy on compound drugs, available at www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/Presc/Policy/SpecCovDec/Compounded.asp.

Services that aren’t covered

Compounded topical preparations containing multiple active ingredients aren’t covered.  There are many commercially available, FDA-approved alternatives, on the Outpatient Drug Formulary such as:

• Oral generic nonsteroidal anti-inflammatory drugs,
• Muscle relaxants,
• Tricyclic antidepressants,
• Gabapentin, and
• Topical salicylate and capsaicin creams.

Link: More information on the Outpatient Drug Formulary is available at www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/Presc/OutpatientDrug.asp.

Requirements for billing

Compounded drug products must be billed by pharmacy providers on the Statement for Compound Prescription with national drug code (NDCs or UPCs if no NDC is available) for each ingredient.

Payment limits

No separate payment will be made for 99070 (Supplies and materials).

 

Payment policy: Hyaluronic acid for osteoarthritis of the knee

Prior authorization

Hyaluronic acid injections are only allowed for osteoarthritis of the knee.  Other uses are considered experimental, and therefore will not be paid.

Link: For more information about treatments that aren’t authorized, see WAC 296-20-03002(6) .

For authorization, the correct side of body HCPCS billing code modifier (–RT or –LT) is required.  If bilateral procedures are required, both modifiers must be authorized.

Requirements for billing

CPT® code 20610 must be billed for hyaluronic acid injections along with and the appropriate HCPCS code:

If the injection is…	Then the appropriate HCPCS billing code is:	Which has a maximum fee of:
Hyalgan or Supartz	J7321	$140.40
Euflexxa	J7323	$246.53
Orthovisc	J7324	$283.50
Synvisc or Synvisc-1	J7325	$20.32 per mg

The correct side of body HCPCS code billing modifier (–RT or –LT) is required for billing.  If bilateral procedures are authorized, both modifiers must be billed as a separate line item.

Additional information: Hyaluronic acid injections

Link: For more information about hyaluronic acid injections, see www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/hyaluronicacid.asp .

Payment policy: Immunizations

Prior authorization

Immunization materials are payable when authorized.  

Services that can be billed

CPT® codes 90471 and 90472 are payable, in addition to the immunization materials code(s).

For each additional immunization given , add-on CPT® code 90472 may be billed.

Payment limits

E/M codes aren’t payable in addition to the immunization administration service, unless the E/M service is:

• Performed for a separately identifiable purpose, and
• Billed with a –25 modifier.

Additional information: Blood-borne pathogens and infectious diseases

Link: For more information on blood-borne pathogens, see www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/PEP/default.asp#1.

For more information about work-related exposure to an infectious disease, s ee WAC 296-20-03005.

 

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Payment policy: Immunotherapy

Services that aren't covered

Complete service codes aren’t paid.  

Requirements for billing

Professional services for the supervision and provision of antigens for allergen immunotherapy must be billed as component services. The provider bills:

• One of the injection codes, and
• One of the antigen/antigen preparation codes.

 

Payment policy: Infusion therapy services and supplies for RBRVS providers

Prior authorization

Regardless of who performs the service, prior authorization is required for any scheduled or ongoing infusion therapy services (including supplies) performed in the office, clinic, or home.

Note: An exception is outpatient services, which are allowed without prior authorization when medically necessary to treat urgent or emergent care situations that arise in an office or clinic.  (See “Services that can be billed,” below.)

With prior authorization, the insurer may cover:

• Implantable infusion pumps and supplies,
• The implantation of epidural or intrathecal catheters, including their revision, repositioning, replacement, or removal, and
• Antispasticity medications by any indicated route of administration when spinal cord injury is an accepted condition (for example, some benzodiazepines, baclofen).

Services that can be billed

Urgent and emergent outpatient services

Outpatient services are allowed when medically necessary to treat urgent or emergent care situations that arise in an office or clinic.  The following CPT®  codes are payable to physicians, ARNPs, and PAs:

• 96360,
• 96361, and
• 96365-96368.

Supplies

Implantable infusion pumps and supplies that may be covered with prior authorization include these HCPCS codes:

• A4220,
• E0782 – E0783, and
• E0785 – E0786.

Placement of non-implantable epidural or subarachnoid catheters for single or continuous injection of medications is covered.

Services that aren’t covered

Intrathecal and epidural infusions of any substance other than anesthetic or contrast material aren’t covered.

Link: For more information, see WAC 296-20-03002 .

Requirements for billing

Equipment and supplies

Durable medical equipment (DME) providers may bill for equipment and supplies required to provide authorized IV infusion therapy under their L&I DME provider account numbers.

If rental or purchase of an infusion pump is medically necessary to treat a patient in the home, refer to the payment policy for “Home infusion services” in the Home Health Services chapter for more information.

Link: For information on home infusion therapy in general, see the “Home infusion services” section of the Home Health Services chapter.

Note: Billing instructions for non-pharmacy providers are detailed in the “Payment policy” for “Injectable medications” (the next section of this chapter).

Drugs

Drugs for outpatient use must be billed by pharmacy providers, either  electronically through the point-of-service (POS) system or on appropriate pharmacy forms (Statement for Pharmacy Services, Statement for Compound Prescription or Statement for Miscellaneous Services) with national drug codes (NDCs or UPCs if no NDC is available).

Note: Total parenteral and enteral nutrition products are exceptions and may be billed by home health providers using the appropriate HCPCS codes.

Payment limits

E/M office visits

Providers will be paid for E/M office visits in conjunction with infusion therapy only if the services provided meet the code definitions.

Opiates

Infusion of any opiates and their derivatives (natural, synthetic or semisynthetic) aren’t covered unless they are:

• Part of providing anesthesia, or
• Short term post operative pain management (up to 48 hours post discharge), or
• Medically necessary in emergency situations.

Link: For more information, see WAC 296-20-03014 .

Equipment and supplies

Infusion therapy supplies and related DME, such as infusion pumps, aren’t separately payable for RBRVS providers.  Payment for these items is bundled into the fee for the professional service).

Note: See definition of bundled in “Definitions” at the beginning of this chapter.

Diagnostic injections

Intravenous or intra-arterial therapeutic or diagnostic injection codes, CPT® codes 96373 and 96374, won’t be paid separately in conjunction with the IV infusion codes.

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Payment policy: Injectable medications

Requirements for billing

Providers must use the HCPCS J codes for injectable drugs that are administered during an E/M office visit or other procedure.

Note: The HCPCS J codes aren’t intended for self administered medications.

When billing for a non-specific injectable drug, the following must be noted on the bill and documented in the medical record:

• Name,
• NDC,
• Strength,
• Dosage, and
• Quantity of drug administered.

Although L&I’s maximum fees for injectable medications are based on a percentage of AWP and the drug strengths listed in the HCPCS manual, providers must bill their acquisition cost for the drugs.  To get the total billable units, divide the:

• Total strength of the injected drug, by
• The strength listed in the manual.

For example:

• You administer a 100 mg injection.
• The HCPCS manual lists the strength as 10 mg.
• Your billable units are 100 mg (administered) divided by 10 mg (strength) = 10 units.

Payment limits

Payment is made according to the published fee schedule amount, or the acquisition cost for the covered drug(s), whichever is less.

 

Payment policy: Medical foods and co-packs

Services that aren’t covered

Medical food products and their convenience packs or “co-packs” aren’t covered.

Examples of medical food products include:

• Deplin® (L-methylfolate), and
• Theramine® (arginine, glutamine, 5-hydroxytryptophan, and choline).

Examples of “co-packs” include:

• Theraproxen® (Theramine and naproxen), and
• Gaboxetine® (Gabadone and fluoxetine).

Link: For more information, see the department’s coverage policy on “Medical foods and co-packs,” available at www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/Presc/Policy/SpecCovDec/MedicalFood.asp.

Payment limits

Medical foods and co-packs administered or dispensed during office procedures are considered bundled in the office visit.

No separate payment will be made for 99070 (Supplies and materials), which is a bundled code.

Note: See the definition of bundled in “Definitions” at the beginning of this chapter.

Payment policy: Non-injectable medications

Services that can be billed

Providers may use distinct HCPCS J codes that describe specific non-injectable medication administered during office procedures.

• Separate payment will be made for medications with distinct J codes.

Note: The HCPCS J codes aren’t intended for self administered medications.

Services that aren’t covered

No payment will be made for pharmaceutical samples.

Requirements for billing

Providers must bill their acquisition cost for these drugs.

The name, NDC, strength, dosage and quantity of the drug administered must be documented in the medical record and noted on the bill.

Link: For more information, see the payment policy for “Acquisition cost” in the Supplies, Materials, and Bundled Services chapter.

 Payment limits

Miscellaneous oral or non-injectable medications administered or dispensed during office procedures are considered bundled in the office visit.  No separate payment will be made for these medications:

• A9150 (Nonprescription drug), or
• J3535 (Metered dose  inhaler drug), or
• J7599 (Immunosuppressive drug, NOS), or
• J7699 (Non-inhalation drug for DME), or
• J8498 (Antiemetic drug, rectal/suppository, NOS), or
• J8499 (Oral prescript drug non-chemo), or
• J8597 (Antiemetic drug, oral, NOS), or
• J8999 (Oral prescription drug chemo).

Note: See the definition of bundled in “Definitions” at the beginning of this chapter.

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Payment policy: Spinal injections

Payment methods

Physician or CRNA/ARNP

The payment methods for physician or CRNA/ARNP are:

• Injection procedure: —26 component of Professional Services Fee Schedule, and
• Radiology procedure: —26 component of Professional Services Fee Schedule

Note: A separate payment for the injection won’t be made when computed tomography is used for imaging unless documentation demonstrating medical necessity is provided.

Radiology facility payment methods

The payment methods for radiology facilities are:

• Injection procedure: No facility payment, and
• Radiology procedure: —TC component of Professional Services Fee Schedule.

Hospital payment methods

The payment methods for hospitals are:

• Injection procedure: APC or POAC (payment method depends on the payer and/or the hospital’s classification), and
• Radiology procedure: APC, POAC or —TC component of Professional Services Fee Schedule.

Note: Radiology codes may be packaged with the injection procedure.

Link: See the Professional Services Fee Schedule at http://feeschedules.Lni.wa.gov.

 

Payment policy: Therapeutic or diagnostic injections

Prior authorization

Required

These services require prior authorization:

• Trigger point and dry needling injections (refer to guideline for limits), and
• Sympathetic nerve blocks (refer to the CRPS guideline).

Note: See the definition of dry needling in “Definitions” at the beginning of this chapter.

Links: For guidelines on trigger point and dry needling injections, see www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/Dryneedling.asp.

For CRPS guidelines, see www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/ComplexRegionalPain.asp.

Required along with utilization review

These services require both prior authorization and utilization review:

• Therapeutic epidural and spinal injections for chronic pain,
• Therapeutic sacroiliac joint injections for chronic pain,
• Diagnostic facet and medial branch block injections (refer to neurotomy guideline), and
• Diagnostic intradiscal injections for discography.

Links: For the coverage decision and guidelines on spinal injections, see www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/Spinalinjections.asp.

For the neurotomoy guidelines, see www.lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/FacetNeurotomy.pdf.

For the coverage decision on discography, see www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/Discography.asp.

Services that can be billed

These services can be billed without prior authorization:

• E/M office visit services provided on the same day as an injection may be payable if the services are separately identifiable,
• Professional services associated with therapeutic or diagnostic injections (CPT® code 96372) are payable along with the appropriate HCPCS J code for the drug,
• Intra-arterial and intravenous diagnostic and therapeutic injection services (CPT® codes 96373 and 96374) may be billed separately and are payable if they aren’t provided in conjunction with IV infusion therapy services (CPT® codes 96360, 96361, 96365-96368), and
• Spinal injections that don’t require fluoroscopy or CT guidance:
  • CPT® code 62270 – diagnostic lumbar puncture,
  • CPT® code 62272 – therapeutic spinal puncture for drainage of CSF, and
  • CPT® code 62273 – epidural injection of blood or clot patch.

Services that aren’t covered

CPT® code 99211 won’t be paid separately.

Note: If billed with the injection code, providers will be paid only the E/M service and the appropriate HCPCS J code for the drug.

The insurer doesn’t cover acupuncture services.

Links: For more information about the coverage decision for acupuncture services, see WAC 296-20-03002 and www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/Acupuncture.asp.

The insurer doesn’t cover therapeutic medial branch nerve block injections, therapeutic intradiscal injections, and therapeutic facet injections.

Links: For more information about these injections, see www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/facetneurotomy.asp.

 

Requirements for billing

Dry needling

Dry needling of trigger points must be billed using CPT® codes 20552 and 20553.

Spinal injections that require fluoroscopy

For spinal injection procedures that require fluoroscopy:

• One fluoroscopy code must be billed along with the underlying procedure code or the bill for the underlying procedure will be denied, and
• Only one fluoroscopy code may be billed for each injection (see table below).

Only one of these CPT® fluoroscopy codes may be billed for each injection …	… and it must be billed along with this underlying CPT® code:
77002, 77012, 76942	62268
77002, 77012, 76942	62269
77003, 72275	62281
77003, 72275	62282
77003, 77012, 76942, 72240, 72255, 72265, 72270	62284
72295	62290
72285	62291
72295	62292
77002, 77003, 77012, 75705	62294
77003, 72275	62310
77003, 72275	62311
77003, 72275	62318
77003, 72275	62319

Spinal injection procedures that include “fluoroscopy,” “ultrasound,” or “CT” in the code description

Paravertebral facet joint injections now include fluoroscopic, ultrasound, or CT guidance as part of the description.  This includes these CPT® codes:

• 64479-64480, and
• 64483-64484, and
• 64490-64495, and
• 0213T-0218T, and
• 0228T-0231T.

Note: Fluoroscopic, ultrasound, or CT guidance can’t be billed separately.

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Links: Related topics

If you’re looking for more information about…	Then go here:
Administrative rules for drug limitations (such as opiates)	Washington Administrative Code (WAC) 296-20-03014: http://apps.leg.wa.gov/wac/default.aspx?cite=296-20-03014
Administrative rules for treatment authorization	WAC 296-20-03002: http://apps.leg.wa.gov/wac/default.aspx?cite=296-20-03002
Administrative rules for work- related exposure to an infectious disease	WAC 296-20-03005: http://apps.leg.wa.gov/wac/default.aspx?cite=296-20-03005
Becoming an L&I provider	L&I’s website: www.Lni.wa.gov/ClaimsIns/Providers/Becoming/default.asp
Billing instructions and forms	Chapter 2: Information for All Providers
Bloodborne pathogens	L&I’s website: www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/PEP/default.asp#1
Complex Regional Pain Syndrome (CRPS) guidelines	L&I’s website: www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/ComplexRegionalPain.asp
Discography guidelines	L&I’s website: www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/Discography.asp
Dry needling and trigger point injections guidelines	L&I’s website: www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/Dryneedling.asp
Fee schedules for all healthcare professional services (including medication administration)	L&I’s website: http://feeschedules.Lni.wa.gov
Hyaluronic acid injections	L&I’s website: www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/hyaluronicacid.asp
Medical coverage decision for acupuncture	L&I’s website: www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/Acupuncture.asp
Medical foods and co-packs coverage policy	L&I’s website: www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/Presc/Policy/SpecCovDec/MedicalFood.asp
Neurotomy guidelines	L&I’s website: www.lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/FacetNeurotomy.pdf
Payment policies for acquisition cost policy	Chapter 28: Supplies, Materials, and Bundled Services
Payment policies for home infusion therapy	Chapter 11: Home Health Services
Spinal injections coverage decision and guidelines	L&I’s website: www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/Spinalinjections.asp

Need more help?  Call L&I’s Provider Hotline at 1-800-848-0811.

CPT® codes and descriptions only are © 2011 American Medical Association