Chapter 17: Modification: Home, Job, and Vehicle

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)

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Table of contents

Definitions

Payment policies:
Home modifications
Job modifications and pre-job accommodations
Vehicle modifications

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 .

Job modifications:

Job modifications are adjustments or alterations made to the way a job is performed to accommodate the restrictions imposed by an industrial injury or occupational disease.  The purpose of job modification benefits is to encourage employers to modify jobs to retain or hire injured workers.  Job modifications are used when an employer/employee relationship exists, and they may include worksite adjustment; job restructuring; and/or tools, equipment or appliances.

Link: For more information, see WAC 296-19A-010(9) .

Pre-job accommodations:

Pre-job are adjustments or alterations made to the way a job is performed to accommodate the restrictions imposed by an industrial injury or occupational disease.  The purpose of pre-job accommodation benefits is to make it possible for the worker to perform the essential functions of a job.  Accommodations are used when an industrially injured or ill worker is engaged in a vocational rehabilitation plan or in a job search, and they may include tools, equipment or appliances.

Link: For more information, see WAC 296-19A-010(10) .

Residence (home) modification:

A residence or home modification is a permanent change to an existing residence or a repair of a modification previously approved and paid for by the department or self-insured employer, or a modification made when constructing a new residence.

Link: For more information, see WAC 296-14-6200 .


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Payment policy: Home modifications

(See definition of home modification in “Definitions” at the beginning of this chapter.)

Prior authorization

A consultation for a:

  • State Fund claimant must be preauthorized by claim manager,
  • Crime Victims claimant must be preauthorized by claim manager, and
  • Self-insured employer claimant, you must contact the employer or their claim management representative for preauthorization.

Construction and design work done for a:

  • State Fund claimant must be preauthorized by the Assistant Director for the Insurance Services Program (AD),
  • Crime Victims claimant must be preauthorized by the Program Manager for the Crime Victims Compensation Program, and
  • Self-insured employer claimant cannot deny without L&I’s AD’s approval.

Who must perform these services to qualify for payment

The home modification consultant must:

  • Be a licensed nurse, occupational therapist, or physical therapist, and
  • Have training or experience in both rehabilitation of catastrophic injuries and modifying homes.

Note: See more information about who can bill for specific services in the “Home modifications fee schedule” below.

Services that can be billed

Home modifications fee schedule, effective July 1, 2011:

For this HCPCS or local billing code The provider that can bill is a: And the insurer pays for: With a maximum fee of:
8914H
Home modification
construction and design
.
  • Contractor,
  • Architect,
  • Construction material supplier, and
  • Worker.
  • Construction materials,
  • Labor & tax,
  • Permits and inspections, and
  • Architect plans.
If the worker pays for inspections,
predesign, or planning services, the
worker may be reimbursed if the
modification request is approved.
Each bill pays by report
(as billed) up to the maximum
amount authorized for the
home modification.
8916H
Home modification
evaluation and
consultation
.
Home modification consultant. Time spent doing:
  • Onsite home evaluation,
  • Consultation, or
  • Required reports.
By report.
8917H
Home modification mileage,
lodging, bridge and
ferry tolls, airfare, and
car rental
.
Home modification consultant. Mileage for travel beyond
10 miles.

Lodging for 1 person when the
onsite visit requires:
  • Two or more consecutive days, and
  • Is greater than 125 miles one way.
Airfare (economy) for 1 person
when travel is greater than 180
miles one way.

Car rental (economy) when air
travel is involved.
State rates.
0391R
Travel.
Home modification consultant. Travel time or wait time $4.83 per unit (1 unit = 6 minutes)

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

Requirements for billing

To get reimbursed, you must submit a copy of receipts for:

  • Materials,
  • Lodging,
  • Airfare, and
  • Car rental.

Payment limits

The maximum payable for all work is the current Washington State average annual wage.

Note: For additional information about home modifications, see links in “Related Topics” at the end of this chapter.


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Payment policy: Job modifications and pre-job accommodations

(See definition of job modification and pre-job accommodation in “Definitions” at the beginning of this chapter.)

Link: More information about job modifications is available online at www.Lni.wa.gov/ClaimsIns/Providers/Vocational/Tools/PreJob/default.asp .

Prior authorization

The need for a job modification or pre-job accommodation must be identified and documented by L&I, the attending health care provider, treating occupational or physical therapist, employer, worker, or vocational rehabilitation counselor.

Job modifications

Prior authorization is required for all job modification services.

Pre-job accommodations

Prior authorization is required for all pre-job accommodations.  Consultations pertaining to a specific job modification or pre-job accommodation must be preauthorized after the need has been identified.  Also:

  • Pre-job accommodation benefits are only available for State Fund claims, however
  • Self-insured employers may cover these costs for self-insured claims.

Who must perform these services to qualify for payment

Consultations

The provider of a job modification or pre-job accommodation consultation must be a:

  • Licensed occupational therapist or physical therapist, or
  • Vocational rehabilitation provider, or
  • Ergonomic specialist.

Pre-job accommodations

The provider of a pre-job accommodation must be a:

  • Occupational therapist, or
  • Physical therapist, or
  • Vocational rehabilitation counselors not associated with the group assigned to the vocational referral, or
  • Ergonomic specialist.

Services that can be billed

Consultation services

In some cases, the department may reimburse for consultation services.

Consultations: Counselors with group assigned to referral

Vocational rehabilitation counselors and interns in the group assigned to the vocational referral must bill using procedure codes 0823V or 0824V.

Link: For more information, see the payment policy for “Vocational evaluation” in the “Additional requirements for all vocational services providers” section of the Vocational Services chapter.

Consultations: Counselors that aren’t with group assigned to referral

The following codes require prior authorization and can be billed by vocational rehabilitation counselors that aren’t associated with the group assigned to the vocational referral:

Billing code Description Activities Maximum fee
0389R Pre-job or job modification
consultation
, analysis of
physical demands
(non-VRC),
per 6 minutes.
Consultation time with worker,
Composing the report,
Communication,
Instruction in work practices,
When indicated:
  • Obtaining bids,
  • Completing and submitting
    assistance application packet,

Analyzing job physical demands to assist a
VRC in completing a job analysis
(qualified PT or OT only).
$10.66
0391R Travel/wait time (non-VRC),
per 6 minutes.
Traveling to work/training site as
part of direct consultation services.
$4.83
0392R Mileage (non-VRC), per mile. Mileage to work/training site as
part of direct consultation services.
State rate
0393R Ferry charges (non-VRC). Ferry travel if required to travel to
work/training site as part of direct
consultation services.
State rate

Note: If services are provided to a worker with an open vocational referral, see “Vocational evaluation and related codes for nonvocational providers” in the Vocational Services chapter (under the “Billing by referral type” payment policy section) for additional information for nonvocational providers.

Authorized equipment vendors

The following codes require prior authorization and can be billed by authorized equipment vendors:

Billing code Description Activities Maximum fee
0380R Job modification Equipment/ tools:
  • Installation,
  • Set up,
  • Basic training in use,
  • Delivery (includes mileage),
  • Tax,
  • Custom modification/ fabrication.

Work area modification
or reconfiguration.
Maximum allowable for 0380R
is $5,000.00 per job or job site.
0385R Pre-job accommodation Equipment/ tools:
  • Installation,
  • Set up,
  • Basic training in use,
  • Delivery (includes mileage),
  • Tax,
  • Custom modification/ fabrication.

Work/ training area modification
or reconfiguration.
Maximum allowable for 0385R
is $5,000.00 per claim.
Combined costs of 0380R and
0385R for the same return to
work goal can’t exceed $5,000.00.

Note: Consultants may supply the equipment/tools only if:

  • Custom design and fabrication of unique equipment or tool modification is required, and
  • Prior authorization is obtained, and
  • Proper justification and cost estimates are provided.

Link: Additional information is available at www.Lni.wa.gov/ClaimsIns/Providers/Vocational/Tools/PreJob/default.asp .

Services that aren’t covered

These services aren’t covered:

  • Performing vocational rehabilitation services as described in WAC 296-19A on claims with open vocational referrals, and

Link: Additional information is available in WAC 296-19A .

  • Activities associated with reports other than composing or dictating complete draft of the report, including:
    • Editing, revising, or typing,
    • Filing, or
    • Distributing or mailing, and
  • Time spent on any administrative and clerical activity, including:
    • Typing,
    • Copying,
    • Faxing, mailing, or distributing,
    • Filing,
    • Payroll,
    • Recordkeeping, or
    • Delivering or picking up mail.

Requirements for billing

PTs, OTs, or ergonomist specialists

For claims wthout an open vocational referral, use the Statement for Retraining and Job Modification Services (F245‑030‑000 ) form.

For claims with an open vocational referral, use the Statement for Miscellaneous Services (F245-072-000 ) form.  

Vocational rehabilitation providers

For claims without an open vocational referral, use the Statement for Retraining and Job Modification Services (F245‑030‑000 ) form.

For claims with an open vocational referral, use the Statement for Miscellaneous Services (F245-072-000 ) form.

Vendors

You can only bill one code: either 0380R or 0385R.

If billing for the Statement for Retraining Job Modification Services (F245‑030‑000 ) form:

  • Use billing code 0380R, and
  • Attach a copy of the Job Modification Assistance Application form signed by the claim manager or therapist consultant, or

If billing for the Statement for Miscellaneous Services (F245-072-000 ) form:

  • Use billing code 0385R, and
  • Attach a copy of the Pre-job Accommodation Assistance Application form, signed by the claim manager.

Note: These forms are supplied to you by the employer, therapist, or vocational counselor, etc.

Payment limits

The combined costs of both codes 0380R and 0385R for same return to work goal cannot exceed $5,000.

For self-insured claims, pre-job accommodations can’t be approved.

Note: Self-insured employers may pay any pre-job accommodation expenses for injured workers who no longer work for them.

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Payment policy: Vehicle modifications

Link: More information about vehicle modifications is available in RCW 51.36.020(7) (see “Modification to residences or motor vehicles”).

Prior authorization

Vehicle modifications require prior authorization based on approval by the Assistant Director of L&I’s Insurance Services Program.

Who must perform these services to qualify for payment

Consultations

The vehicle modification consultant must:

  • Be a licensed occupational or physical therapist, or licensed medical professional, and
  • Have training or experience in both rehabilitation and vehicle modification.

Services that can be billed

If the HCPCS and local billing code is… Then the provider who can bill is: And L&I pays for: And the maximum fee is:
8915H:
Vehicle modification
Contractor Vehicle modification Maximum payable for all work
is ½ the current Washington
State average wage
.
The amount paid may be increased
by no more than $4,000.00 by
written order of the Supervisor
of Industrial Insurance (see “Link”
below table).
8917H:
Vehicle modification
mileage, lodging, bridge
and ferry tolls, airfare, and
car rental
Vehicle modification
consultants
Mileage for travel beyond
10 miles.
Lodging for 1 person when
the onsite visit requires:
  • Two or more consecutive days, and
  • Is greater than 125 miles one way.

Airfare (economy) for 1
person when travel is greater
than 180 miles one way.
Car rental (economy) when
air travel is involved.
State rates
0391R:
Travel
Vehicle modification
consultants
Travel time or wait time $4.83 per unit
(1 unit = 6 minutes)

Link: For more information about vehicle modification payment increases, see RCW 51.36.020(8)(b) .

Requirements for billing

To get reimbursed, you must submit copies of receipts for:

  • Lodging,
  • Airfare, and
  • Car rental.

Payment limits

For local billing code 8915H, the maximum payable for all work is 50% of the current Washington State average wage.  The amount paid may be increased by no more than $4,000.00 by written order of the Supervisor of Industrial Insurance.

Link: For more information about vehicle modification payment increases, see RCW 51.36.020(8)(b) .


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If you’re looking for more information about… Then go here:
Administrative rules
for home modifications
Washington Administrative Code (WAC) 296-14-6200:
http://apps.leg.wa.gov/WAC/default.aspx?cite=296-14-6200
WAC 296-14-6238:
http://apps.leg.wa.gov/WAC/default.aspx?cite=296-14-6238
Administrative rules
for vocational rehabilitation
Washington Administrative Code (WAC) 296-19A:
http://apps.leg.wa.gov/WAC/default.aspx?cite=296-19A
Becoming an L&I provider L&I’s website:
www.Lni.wa.gov/ClaimsIns/Providers/Becoming/default.asp
Billing instructions and forms Chapter 1:
Introduction
Contractors’ questions and answers
about home modifications for workers
with catastrophic injuries
L&I’s website (form F252-061-000):
www.lni.wa.gov/IPUB/252-061-000.pdf
Fact sheet on home modifications
for workers with catastrophic injuries
L&I’s website (form F252-060-000):
www.lni.wa.gov/IPUB/252-060-000.pdf
Fee schedules for all healthcare
and vocational services
L&I’s website:
www.Lni.wa.gov/ClaimsIns/Files/ProviderPay/FeeSchedules/2011FS/fsAll.xls
Home Modification Acknowledgement
of Responsibilities
form
L&I’s website (form F247-003-000):
www.lni.wa.gov/forms/wordforms/247003a0.doc
Home modifications policies L&I’s website:
www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/HomeModification.asp
Job modifications and pre-job
accommodations policies
L&I’s website:
www.Lni.wa.gov/ClaimsIns/Providers/Vocational/Tools/PreJob/default.asp
Laws for definitions Revised Code of Washington (RCW) 50.04.355:
http://apps.leg.wa.gov/rcw/default.aspx?cite=50.04.355
Laws for modification to
residences or motor vehicles
RCW 51.36.020(7):
http://apps.leg.wa.gov/rcw/default.aspx?cite=51.36.020
Laws for residence
modification services
RCW 51.36.022:
http://apps.leg.wa.gov/rcw/default.aspx?cite=51.36.022
Laws for “right to” and amount RCW 51.32.095(4):
http://apps.leg.wa.gov/rcw/default.aspx?cite=51.32.095
RCW 51.32.250:
http://apps.leg.wa.gov/rcw/default.aspx?cite=51.32.250
Miscellaneous Services
Billing Instructions
L&I’s website:
www.lni.wa.gov/forms/pdf/F248-095-000.pdf
Statement for Miscellaneous
Services
billing form
L&I’s website:
www.lni.wa.gov/FormPub/Detail.asp?DocID=1627
Statement for Retraining and
Job Modification Services
form
L&I’s website:
www.lni.wa.gov/Forms/pdf/F245-030-000.pdf

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


 

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