Chapter 1: Introduction

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

 

 

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Effective July 1, 2011

Complete Chapter for printing

(Republished February 1, 2012)

Look for possible updates and corrections to these payment policies

 

Table of contents

Definitions

General information:
About this manual
About the new design and layout
Highlights of policy changes since July 1, 2010
Tips on finding information in the printable version

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 can bill HCPCS codes listed as bundled in the fee schedules.  This is because, for these provider types, there isn’t an office visit or a procedure into which supplies can be bundled.

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


General information: About this manual

What is MARFS?

The Medical Aid Rules and Fee Schedules (MARFS) is a package of information about how workers’ compensation insurers in Washington State pay for healthcare and vocational services provided to injured workers and crime victims.

MARFS includes three things:

  • Medical aid rules published in the Washington Administrative Codes (WACs) for industrial insurance (workers’ compensation),
  • Fee schedules for healthcare and vocational professional provider and facility services, and
  • This payment policies manual.

What is in this manual?

This manual contains 36 chapters, plus appendices, of payment policies for healthcare and vocational services provided by individual professional providers or facilities.

A payment policy for a specific service can include information about:

  • Prior authorization,
  • Who must perform specific services to qualify for payment,
  • Services that can be billed or that aren’t covered,
  • Requirements for billing,
  • Payment limits, or
  • Other information, such as payment methods, background information on coverage decisions, unique requirements, and examples to illustrate billing procedures.

NoteReference Note: Not every payment policy includes all of these elements.  When one of the above elements isn’t included, it is because the information isn’t applicable.  When the elements do appear, they are consistently presented in the same order.

Beyond this introductory chapter, in this manual you will find:

  • One chapter on general policies and information for all providers,
  • 29 professional services chapters, which contain payment policies for individual professional healthcare and vocational providers, and interpreters,
  • 5 facility services chapters, which contain payment policies for healthcare facilities, and
  • Appendices containing information that applies to all chapters.

NoteReference Note: Within each of the services sections, the chapters appear alphabetically.

What part of MARFS isn’t in this manual?

This manual doesn’t include:

  • Fee schedules, which contain the maximum fees (payment amounts) for the authorized billing codes providers use to bill for services,
  • The field key, which explains the column headings and abbreviations that appear in the fee schedules,
  • Medical aid rules, which are the L&I specific WACs, or
  • Updates and Corrections,” which contains any changes to policies and fees that occur between annual publications of this manual (see more about these changes, below, under, “How do I know if a policy is current?”).

LinkReferenceLinks: The fee schedules (including the field key) are available on L&I’s website, at http://feeschedules.Lni.wa.gov.

Medical Aid Rules are available in “Title 296 WAC” on the Washington State Legislature’s website, at http://apps.leg.wa.gov/wac/default.aspx?cite=296.

How do I know if a policy is current?

The policies in this manual are updated and published at the start of each fiscal year (July 1), and are effective for services provided on or after that date (until the next publication of this manual).

Sometimes changes do occur between publications of this manual.  Such changes are communicated to providers through L&I’s Medical Provider News email listserv and are also documented on an “Updates & Corrections” page on L&I’s website.

LinkReferenceLinks: To see the “Updates and Corrections” webpage, go to www.Lni.wa.gov/ClaimsIns/Providers/Billing/FeeSched/2011/default.asp#3.

For information about how to join the email listserv, see the “General information: All payment policies and fee schedules” section of Chapter2: Information for All Providers.
  

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General information: About the new design and layout

Overview

On February 1, 2012, L&I published a new design and layout for the MARFS Payment Policies manual to make it easier for our customers to search through and track down information.  Extensive user testing and feedback helped us discover the best way to reorganize and redesign the manual, including:

  • Organizing payment policies for general types of services into individual chapters,
  • Using a simpler, cleaner layout with more white space,
  • Using plain language more,
  • Labeling specific types of information (such as “Prior authorization,” “Services that can be billed,” “Requirements for billing,” or “Payment limits”) and presenting it in a consistent, predictable order,
  • Providing more direct links to related topics,
  • Using visual cues to make it easier to see specific types of content (see more about these visual cues, below), and
  • Having chapters available both as webpage and printable (“PDF”) formats.

How is each chapter organized?

Each chapter contains:

  • A title page with a “Table of contents” for the chapter,
  • Followed by payment policies for specific services, or general information, and
  • At the end of the chapter, a table with links to related topics.

Some chapters also include definitions of key terms, including descriptions of billing code modifiers.  When a chapter does contain definitions, they appear immediately following the “Table of contents.”

Visual cues

In the new design, visual cues and icons appear consistently throughout the payment policies manual.  The following is a list of these icons and visual cues, with descriptions of how they are used:

Bulleting:

Bullet lists are used to organize complex information and break it up into manageable pieces.

Link:LinkReference

Direct links to related information that may be of interest and assistance are provided.  These include links to other chapters within the payment policies manual, to internet website addresses, or to specific WACs and RCWs.

Note: NoteReference
Notes appear throughout the manual to draw attention to additional useful information.

Table of contents: TOC

The same icon always appears next to the “Table of contents.”

Definitions or general policy information:  TOC

The same icon always appears next to “Definitions” or next to general policies that aren’t payment policies.

Payment policy:  TOC

The same icon always appears next to each payment policy.

Sample pages

Below are illustrations of actual chapter content (from the printable version of the manual) to show how information appears throughout.

Sample title page:

SampleTitlePage

Sample payment policy page:

SamplePaymentPolicypage

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General information: Highlights of policy changes since July 1, 2010

NoteReference Note: These highlights are intended for general reference; they aren’t a comprehensive list of all the changes in the payment policies or fee schedules.

For complete code descriptions and lists of new, deleted, or revised codes, refer to the 2011 CPT© and HCPCS coding books.

Washington Administrative Code (WAC) and payment changes

The following changes to WACs and payment rates occurred:

  • Cost of living adjustments weren’t applied to RBRVS and anesthesia services or to most local codes,
  • WAC 296-20-135 reduces the RBRVS conversion factor to $55.34 while the anesthesia conversion factor remains at $3.19 per minute ($47.85 per 15 minutes),
  • WAC 296-23-220 and WAC 296-23-230 maintain the maximum daily cap for physical and occupational therapy services at $118.07, and
  • WAC 296-23-250 set a daily cap for massage therapy of 75% of the daily cap for PT/OT services.  The rate for July 1, 2011 will remain $88.55.

Policy & fee schedule additions, changes, and clarifications

Introductory chapters

In Chapter 2: Information for All Providers, added a new section addressing self-insurers.

Professional services chapters

In the professional services chapters:

  • Updated the telephone call policy to cover detailed messages,
  • Revised the list of injection codes that now include diagnostic imaging in the description,
  • Revised the examples for billing physical therapy services,
  • Expanded the work conditioning policy,
  • Added a new policy on drug screens,
  • Outlined coverage for buprenorphine and buprenorphine/Naloxone,
  • Independent Medical Exam section includes new codes for no shows for neuropsychological testing and PCEs scheduled by the department, and
  • Interpretive services section reflects new telephone interpreter services.

Facility services chapters

In the facility services chapters, fees including Hospital AP DRG and Per Diem rates have been updated.

Appendices

In the Appendices:

  • The Preferred Drug List has been updated, and
  • Other appendices have been updated with new codes.

Fee schedules

With the exception of the comma delimited files, the Field Keys are integrated into the fee schedules.

A new fee schedule for medical and surgical supplies has been established for suppliers who routinely bill for these items.  Items listed in the Professional Fee Schedule as bundled will remain bundled for other providers.

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

The following fee schedules have been updated:

  • Professional fees,
  • Durable medical equipment fees,
  • Prosthetics and orthotics fees,
  • Laboratory fees,
  • Pharmacy fees,
  • Dental fees,
  • Interpreter fees,
  • Hospital AP DRG outlier thresholds,
  • Hospital percent of allowed charge (POAC) factors,
  • Hospital rates,
  • Hospital ambulatory payment classification (APC) rates,
  • Residential fees, and
  • Ambulatory surgery center (ASC) fees.

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General information: Tips on finding information in the printable version

To navigate through this manual

Table of contents

In the “Table of contents,” the page numbers are links to the page.

“Bookmarks”

The “Bookmarks” tab (see the far left of this manual in the PDF viewer) is a feature of Adobe Acrobat.  You can use the bookmark links to jump around this manual.  If the “Bookmarks” tab isn’t open, you can open it by clicking on “Bookmarks”:

  • Click on any text in the list to go to the information within this manual,
  • Click on the plus (+) sign to open each section’s list for more information, and
  • Click on the minus (-) sign to close the section.

Search

The “Find” box is another feature of Adobe Acrobat.  Follow the instructions to search for the item or topic you need.

To search for a word, press “Ctrl+F.”  Follow the instructions to search for the item or topic you need.

NoteReference Note: In Adobe Acrobat, the search function won’t find an item if it is misspelled.

Hyperlinks

Use the two kinds of hyperlinks within this manual.  Internal jump links are similar to the “Bookmark” links mentioned above.

To find information on a specific procedure

There are two places to look for information about a specific procedure:

Review the payment policy, (which is inside this manual), or

Review the fee schedule, (which is outside of this manual).

LinkReferenceLink: The fee schedules are available at http://feeschedules.Lni.wa.gov.

To print information within this manual

Use the “Print” icon, which is on the same menu as the “Binocular Search” icon.

NoteReference Note: This print feature will give you options specific to printing this Adobe Acrobat file (PDF), which allows you to print a specific page or the entire document.


If you’re looking for more information about… Then go here:
Administrative rules
for industrial insurance (workers’
compensation)
Washington Administrative Code (WAC) Title 296:
http://apps.leg.wa.gov/wac/default.aspx?cite=296
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 professional
services
L&I’s website:
http://feeschedules.Lni.wa.gov

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


 

CPT® codes and descriptions only are © 2010 American Medical Association

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