Med-Legal visits are not covered under the new billing regulations.  We have received word, however, that providers are receiving denials that Med-Legal bills must be submitted according the the new guidelines.

It may be easiest to submit Med-Legal bills in accordance with the new regulations, but for those who choose to appeal denials, see the following except from the Medical Billing and Payment Guide:

MLs Not Applicable

The OMFS defines standard office hours as Monday through Friday 7am to 6pm. Holidays are Christmas, New Years, Memorial Day, Thanksgiving, Fourth of July and Labor Day.

Are you seeing patients outside of standard business hours or on holidays? If so, you should be billing a code in addition to your Evaluation and Management (E&M) code.

Only one of the following codes can be billed in addition to E&M code. Please note that you cannot bill any of these codes if you are billing an E&M code for emergency department services (99281-99285).

• 99050: Services provider after office hours (reimbursement is $22.20)

  99052: Services provided between 6pm and 7am in response to a request received during those hours (reimbursement is $23.37)

• 99054: Services provided on Sundays or holidays (reimbursement is $25.12)

  99056: Services provided at the request of the patient in a location other than the provider’s office and which are normally provided in the office (reimbursement is $26.88)

• 99058: Office services provided on an emergency basis, for medical emergencies only (reimbursement is $28.63)

Box 19 is used when Required Documents or other supporting documentation are submitted SEPARATELY from the original bill for medical services. Refer to the California Workers’ Compensation Guide regarding Attachment Information for the data requirements to populate this Box.

The relevant data should be entered as follows:  the three digit ID qualifier, followed by the appropriate two digit Report Type Code, the appropriate two digit Transmission Type Code, and the unique Attachment Control Identification number. There should be no spaces between qualifiers and data.

Under all circumstances, information submitted separately tends to slow down the process of bill processing.   For efficient and minimally painful medical payment, all reports and supporting documentation should be submitted with the original bill.

CMS 1500 Box 19

We’re bringing together the disparate information about duplicate bills, revised bills, and appeals, simplifying and expanding on an earlier post.  We’ve tried to disentangle the CMS definitions and requirements, as well as set out the codes and reference numbers, if any, that need to be entered into Boxes 10d and 22.

CMS 1500 Duplicate Bills

CMS 1500 Revised Bills

On Form CMS 1500, Box 17 is required to be filled out when other providers are associated with the bill; when there’s a referring provider.

If the referring provider has an NPI#, Box 17b must be populated with it.

If the referring provider doesn’t have an NPI#, in Box 17a the qualifier “OB” followed by the State License Number of the provider must be entered.

As with all other patient information, it’s best when this information is collected when an appointment is made or at the time of registration.  Also, while a provider is speaking to an adjuster to obtain treatment authorization, for convenience the provider should verify any referring provider information.

CMS Form 1500 Box 17

CMS Form 1500 Box 17b

CMS Form 1500 Box 17a

The Workers’ Compensation Claim Form, DWC 1, is the first document that starts the process rolling for Workers’ Comp medical compensation.  Both the employer and the employee must fill it out accurately and completely and a copy must be sent to the insurer or claims administrator.  Without this document, nothing can happen on any workers’ comp claim.

If a patient is seen on an emergency basis and the work comp claim has not yet been filed, the injured worker should fill this out upon registration.

DWCForm1

In order to make authorization as painless as possible for everyone, we recommend an Authorization Letter such as the one linked below, to be sent out to adjusters prior to a provider seeing a patient. The letter very plainly sets out the kinds of information that need to be collected to minimize hiccups in medical billing later on.  E.g., the form has fields for the adjuster or company’s name, the method of transmission of the Authorization Letter, and the specific number or address to which the Authorization Letter is sent.  This type of information ready to hand can makes appeal much faster and headache-free, if such appeals are necessary.

Authorization Letter

As we’ve said here often, it behooves providers to get accurate and complete information before a patient is seen.  This is true for payment processing by any insurer, but especially by Workers’ Compensation.  Linked below is a form that we recommend be filled out for each and every patient, preferably before or at the time of scheduling the first appointment.

Note that in addition to patient information, this template also makes sure that vital medical billing information is collected, such as the employer name, work comp claim number, and adjuster-obtained data such as the identity of the PTP and the appointment type.

Scheduling Template

There have been many questions regarding the form that the DWC Billing Regulations require.

Specifically, the CMS 1500 form (version 08/05) is required unless there is a written contract agreed to by the parties specifying something different.  A link is given in the regulations showing where to obtain the required form.  Additionally, the regulations reference and incorporate the instructions in the NUCC reference manual. With the exception of the specific requirements outlined in the DWC regulations, the CMS should be completed as instructed in the NUCC reference manual.

Form 1500 may be obtained here

The NUCC manual for CMS 1500 can be accessed here

The regulations and links are cited below.