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:
Case management records and reports
Nurse case management (NCM)

More info:
Related topics

Definitions

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.  

Nurse case management (NCM):

A collaborative process used to meet worker’s healthcare and rehabilitation needs.  The nurse case manager:

• Works with the attending provider, worker, allied health personnel, and insurers’ staff to assist in locating a provider and/or with coordination of the prescribed treatment plan, and
• Organizes and facilitates timely receipt of medical and healthcare resources and identifies potential barriers to medical and/or functional recovery of the worker, and
• Communicates this information to the attending doctor, claim manager, or ONC to develop a plan for resolving or addressing the barriers.

 

Payment policy: Case management records and reports

Requirements for reports

Nurse case management reports must be completed monthly.

Initial assessment, monthly, progress, and closure reports must include all of the following information:

• Type of report (initial, progress, or closing), and
• Worker name and claim number, and
• Report date and reporting period, and
• Worker date of birth and date of injury, and
• Contact information, and
• Diagnoses, and
• Reason for referral, and
• Current medical status, and
• Recommendations for future actions, and
• Actions taken and dates, and
• Ability to positively impact a claim, and
• Health care provider(s) name(s) and contact information, and
• Psychosocial/economic issues, and
• Vocational profile, and
• Hours incurred to date on the referral, and
• Amount of time spent completing the report.

Requirements for records

Case management records must:

• Be created and maintained on each claim, and
• Present a chronological history of the worker’s progress in NCM services.

Requirements for case notes

Case notes must be written when a service is given and must specify:

• When the service was provided, and
• What type of service was provided using local billing codes, and
• Description of the service provided including subjective and objective data, and
• How much time was spent providing each service.

Payment limits

Payment is restricted to:

• Up to 2 hours (20 units) for initial reports, and
• Up to 1 hour (10 units) for progress and closure reports.

Payment policy: Nurse case management (NCM)

(See definition of nurse case management in "Definitions" at the beginning of this chapter.)

Prior authorization

NCM services

Prior authorization by the insurer’s claim manager or L&I’s ONC is required for NCM services.  Contact the insurer to make a referral for NCM services.

Workers must meet one or more of these criteria to be selected to receive NCM services:

• Catastrophic work related injuries, and/or
• Moved out of state and need assistance locating a provider, and/or
• Medically complex conditions, and/or
• Barriers to successful claim resolution.

Expenses

The claim manager must give prior authorization to reimburse for expenses for:

• Parking,
• Ferry,
• Toll fees,
• Cab,
• Lodging, and
• Airfare

Note: These expenses correspond to local billing code 1225M and have a payment limit of $725.00 (see “Requirements for billing” and “Payment limits,” below).

  

Who must perform these services to qualify for payment

To qualify for payment, NCM services must be performed by a registered nurse:

• With case management certification, and
• Who is aware of resources in the worker’s location.

Services that aren't covered

Expenses that aren’t covered include:

• Nurse case manager training,
• Supervisory visits,
• Postage, printing and photocopying (except medical records requested by L&I),
• Telephone/fax equipment,
• Clerical activity (for example: faxing documents, preparing documents to be mailed, organizing documents, etc.),
• Travel time to post office or fax machine,
• Wait time exceeding 16 hours,
• Fees related to legal work, such as deposition and testimony (see “Note,” below), and
• Any other administrative costs not specifically mentioned above.

Note: Legal fees may be charged to the requesting party, but not the claim.  

Requirements for billing

Local billing codes

Nurse case managers must use the following local billing codes to bill for NCM services, including nursing assessments:

• 1220M (Phone calls, per 6 minute unit), which has a maximum fee of $9.72,
• 1221M (Visits, per 6 minute unit), which has a maximum fee of $9.72,
• 1222M (Case planning, per 6 minute unit), which has a maximum fee of $9.72,
• 1223M (Travel/Wait, per 6 minute unit – 16 hour limit), which has a maximum fee of $4.78,
• 1224M (Mileage, per mile – greater than 600 miles requires prior authorization from the claim manager), which pays at the state rate, and
• 1225M (Expenses – parking, ferry, toll fees, cab, lodging, and airfare – at cost or state per diem rate – meals and lodging.  Requires prior authorization from the claim manager – $725 limit), which pays by report.

Note: Also see “Prior authorization,” above, and “Payment limits,” below.

For a definition of by report, see “Definitions” at the beginning of this chapter.

Billing units

When billing for the local codes for NCM services (listed above), units are whole numbers only (don’t use tenths of units), and 1 unit of service equals:

• Each traveled mile, or
• Each 6 minutes of phone calls, visits, case planning, or travel/wait time (see table below), or
• Each related travel expense.

If the time is…	Then bill:
6 minutes	1 unit
12 minutes	2 units
14 minutes	3 units
24 minutes	4 units
30 minutes	5 units
36 minutes	6 units
42 minutes	7 units
48 minutes	8 units
54 minutes	9 units
60 minutes	10 units

Payment limits

NCM services

NCM services are capped at 50 hours of service, including professional and travel/wait time.

Note: An additional 25 hours may be authorized after staffing with the insurer. For State Fund claim, please contact the ONC. Further extensions may be granted in exceptional cases, contingent upon review by the insurer. For State Fund claim, please contact the ONC

Expenses

Local billing code 1225M has a payment limit of $725.00.  (Also see “Prior authorization” and Requirements for billing,” above.)

Links: Related topics

If you’re looking for more information about…	Then go here:
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
Fee schedules for all healthcare services	L&I’s website: http://feeschedules.Lni.wa.gov
“Miscellaneous Services Billing Instructions”	Call L&I’s Provider Hotline to request a copy (see telephone number below this table)

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

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