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Chapter 1: Introduction


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



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Effective July 1, 2018

Complete Chapter for printing

Look for possible updates and corrections to these payment policies

 

Table of contents

General information:
About MARFS and this manual
About the layout and design
Highlights of policy changes since July 1, 2017
Tips on finding information in the printable version

More info:
Related topics




General information: About MARFS and 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, 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 chapters for professional services, which contain payment policies for individual professional healthcare and vocational providers, and interpreters, and
  • five chapters for facility services, which contain payment policies for healthcare facilities.

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://app.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/2018/Updates2018.asp.

For information about how to join the email listserv, see the “General information: All payment policies and fee schedules” section of Chapter 2: Information for All Providers.
  

General information: About the layout and design

 

How is each chapter organized?

Payment policies for general types of services are organized into individual chapters.

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

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

General information: Highlights of policy changes since July 1, 2017

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 2017 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 were applied to RBRVS and anesthesia services or to most local codes,
  • WAC 296-20-135 increases the anesthesia conversion factor to $3.47 per minute ($52.05 per 15 minutes) while the RBRVS conversion factor increases at $64.74,
  • WAC 296-23-220 and WAC 296-23-230 increases the maximum daily cap for physical and occupational therapy services to $127.70, 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, 2018 increases to $95.78.

Policy & fee schedule additions, changes, and clarifications

Professional services chapters

  • In Chapter 2: Information for All Providers, Type of services codes are now listed under the definition section. Also, State Fund encourages providers with multiple accounts under the same tax ID to also include the individual account number for the location billing in box 24J of the CMS 1500. This reduces payment delays.
  • In Chapter 5: Audiology and Hearing Services, the provider who performed the testing must bill for the testing.
  • In Chapter 11: Home Health Services, the chapter has been reorganized into sections that address long term and short term care. New codes for home health services have been added and one has been deleted.
  • In Chapter 18: Modification: Home, Job, and Vehicle, 8918H now Vehicle modification consultation or driving evaluation code for time spent doing onsite vehicle and/or driving evaluation, consultation, or required reports.
  • In Chapter 20: Nurse Case Management, Nurse Case Management, links are included to the optional reporting templates for the Nurse Case Management Initial Care Management Plan, and the Nurse Case Management Progress Report.
  • In Chapter 30: Vocational Services, a payment policy was added that addresses Option 2 vocational services.

 

Facility services chapters

In the facility services chapters, fees including Hospital APR DRG rates have been updated.

Fee schedules

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

The following fee schedules, factors, and rates have been updated:

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

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://app.leg.wa.gov/wac/default.aspx?cite=296
Becoming an L&I provider L&I’s website:
www.Lni.wa.gov/ClaimsIns/Providers/Becoming/
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 ® only copyright 2017 American Medical Association. All rights reserved.

 

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