FLORIDA WORKERS’ COMPENSATION Reimbursement Manual

JIMMY PATRONIS

FLORIDA'S CHIEF FINANCIAL OFFICER

FLORIDA WORKERS' COMPENSATION

Reimbursement Manual

for Ambulatory Surgical Centers

2018 Edition

Rule 69L-7.100, F.A.C.

Effective ________________

Prepared by: Division of Workers' Compensation Department of Financial Services

Connect with us:

Division/WC/

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Table of Contents

Reimbursement Manual Contents

Introduction & Overview

E-Alert System .........................................................................................................................................................................4 How to Obtain or Purchase Hard Copy Manuals ......................................................................................................4 Manual Updates .....................................................................................................................................................................4

Program Requirements

Purpose ......................................................................................................................................................................................5 Prior Authorization of Services .........................................................................................................................................5 Provider Use of Codes, Descriptions, and Modifiers................................................................................................5

Medical Records

Disclosure to Carriers............................................................................................................................................................7 Disclosure to Injured Workers, Employers, and Carriers...............................................................................7 Division or Judge of Compensations Claims Requests ...........................................................................................7

Description of ASC Facility Services

ASC Facility Services..............................................................................................................................................................8 Services Included in ASC Fee(s)........................................................................................................................................8 ASC Services and Components ........................................................................................................................................8 Reimbursement of Components......................................................................................................................................8

Determining Reimbursement Amounts

Reimbursement for Surgical Services.......................................................................................................................... 10 Pathology/Laboratory Services...................................................................................................................................... 10 Radiology/Imaging Services Prior to Admission .................................................................................................... 10 Radiology/Imaging Services Performed on the Day of Surgery ..................................................................... 11 Surgical Implant Reimbursement ................................................................................................................................. 11 Billing for Surgical Implant(s) ......................................................................................................................................... 11 Undocumented Surgical Implant Charges ................................................................................................................ 12 Certification of Surgical Implant Reimbursement Amount ................................................................................ 13 Multiple Surgery Reimbursement Amount............................................................................................................... 14 Billing and Reimbursement for Bilateral Procedures ............................................................................................ 14 Reimbursement for Bilateral Procedures Not Listed as Bilateral in CPT?..................................................... 14 Post-Operative Pain Management............................................................................................................................... 15 Terminated Procedures..................................................................................................................................................... 15

Disallowed, Denied, and Disputed Charges .....................................................................................................................17

Billing Instructions and Forms .....................................................................................................................................................18

Maxmimum Reimbursement Allowances (MRA)........................................................................................................21

Definitions .......................................................................................................................................................................................................23

Form DFS-F5-DWC-90 Completion Instructions .........................................................................................................24

Florida WC Reimbursement Manual for Ambulatory Surgical Centers 2018 Edition, Effective ____________

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Table of Contents

Appendix A: Workers' Compensation Unique Procedure Codes .................................................................25

The five character codes included in the Florida Workers' Compensation Reimbursement Manual for Ambulatory Surgical Centers, 2018 Edition, are obtained from the Current Procedural Terminology (CPT), copyright 2017 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures. The responsibility for the content of the Florida Workers' Compensation Reimbursement Manual for Ambulatory Surgical Centers, 2018 Edition, is with DFS and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences of liability attributable of related to any use; nonuse or interpretation of information contained in the Florida Workers' Compensation Reimbursement Manual for Ambulatory Surgical Centers, 2018 Edition, fee schedules, relative value units, conversion factors, and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Any use of CPT outside of the Florida Workers' Compensation Reimbursement Manual for Ambulatory Surgical Centers, 2018 Edition, should refer to the CPT, which contains the complete and most current code listings and descriptive terms.

CPT is a registered trademark of the American Medical Association.

Florida WC Reimbursement Manual for Ambulatory Surgical Centers 2018 Edition, Effective ____________

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Introduction & Overview

Introduction & Overview

Changes to the Manual

It is important that Ambulatory Surgical Centers (ASCs) and carriers read the updated material in the Florida Workers' Compensation Reimbursement Manual for Ambulatory Surgical Centers (Manual). Both parties have a responsibility for performing specific duties when billing, reporting, or reimbursing medical services rendered to injured workers.

Reimbursement Manuals are available under the "Reimbursement Manuals" section on the Division of Worker's Compensation (DWC) website at Division/WC/.

E-Alert System

The DWC has an electronic alert (e-Alert) system to notify subscribers of news impacting the Workers' Compensation industry and dates of upcoming public meetings and workshops. To subscribe to the e-Alerts, please go to the DWC website, Division/WC/. Look for the "Register" link near the bottom of the page. Once completed, you will receive e-Alerts whenever they are provided by DWC.

Background

There are three different Workers' Compensation Reimbursement Manuals:

? Florida Workers' Compensation Reimbursement Manual for Ambulatory Surgical Centers, Rule 69L-7.100, Florida Administrative Code (F.A.C.);

? Florida Workers' Compensation Health Care Provider Reimbursement Manual, Rule 69L-7.020, F.A.C.;

? Florida Workers' Compensation Reimbursement Manual for Hospitals, Rule 69L-7.501, F.A.C.

Other Applicable Rules

In addition to this Manual, Rule 69L-7.100, F.A.C., also recognizes the following resource: The DWC Medical Reimbursement and Utilization Review, Rule Chapter 69L-7, F.A.C.

Legal Authority

The following statutes and rule chapter govern workers' compensation billing, filing, and reporting in Florida: ? Chapter 440, Florida Statutes (F.S.) F.S.

? Rule Chapter 69L-7, F.A.C. ? The specific Florida Statutes and Florida

Administrative Code for each service are cited for reference in each specific manual, where appropriate.

How to Obtain or Purchase Hard Copy Manuals

This Manual can be obtained free of charge on DWC's website at , under the "Reimbursement Manuals" section, or purchased in hard copy from the Department of Financial Services, Document Processing Section, at 200 East Gaines Street, Tallahassee, Florida 32399-0311.

Reimbursement Manual Updates

The Manual must be updated through rulemaking. Each time the Manual is updated, a revised effective date will be provided at the bottom of each page.

Florida WC Reimbursement Manual for Ambulatory Surgical Centers 2018 Edition, Effective ____________

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Program Requirements

Program Requirements

Purpose

The Manual contains the Maximum Reimbursement Allowances (MRAs) for surgical procedures performed in the ASC setting and defines a payment method for surgical and non-surgical services not defined in the fee schedule.

Unless otherwise specified in this Manual, the terms "insurer" and "carrier" are used interchangeably and have the same meanings as defined in section 440.02, F.S., and may also refer to a service company, third party administrator (TPA), or any other entity acting on behalf of a carrier for the purposes of administering workers' compensation benefits for its insured(s).

Carrier Responsibilities

A carrier is responsible for meeting its obligations under this Manual regardless of any business arrangements with any service company/TPA, submitter, or any entity acting on behalf of the carrier under which claims are paid, adjusted and paid, disallowed, denied, or otherwise processed and submitted to the Division.

At the time of authorization for medical service(s), a carrier must notify each ASC, in writing, of additional form completion requirements or supporting documents that are necessary for reimbursement, inform the ASC of any apportionment, if known, and provide the specific address for submitting a reimbursement request.

Prior Authorization of Services

Both Florida ASC facilities and out-of-state facilities must be authorized by the workers' compensation carrier or a self-insured employer prior to:

? Rendering initial care, remedial medical services, and pharmacy services; or

? Making a referral for the injured worker to facilities or other health care providers.

Exceptions to prior authorization are:

? Federal facilities; ? Emergency services and care, defined in

section 395.002, F.S.; or

? A provider referral for emergency treatment resulting from emergency services.

Documenting Prior Authorization

The ASC must record the authorization in the injured worker's medical record or in the ASC's billing records or financial record(s) and must include:

? The date(s) on which the authorization was

requested and received (whether verbally or in writing);

? The name of the carrier or its designated

entity; and

? The name of the person authorizing the ASC

services.

Provider Use of Codes, Descriptions, and Modifiers

An ASC must use the codes, descriptions, modifiers, guidelines, definitions, and instructions of the incorporated reference material as specified in Rule 69L-7.100, F.A.C., and the following completion instructions incorporated by reference in Rule Chapter 69L-7, F.A.C.:

? Form DFS-F5-DWC-9-C, Completion Instructions for Ambulatory Surgical Centers, Rev. 01/01/2015 (only for dates of service prior to 07/08/2010); or

? Form DFS-F5-DWC-90-B (UB-04), Completion Instructions for Ambulatory Surgical Centers, Rev. 12/08/2015 (only for dates of service on or after 07/08/2010).

All diagnosis codes must be reported to their highest level of specificity according to the diagnosis code and descriptions in the ICD? Manual.

Carrier Use of Codes, Descriptions, and References

Carriers must use the codes, descriptions, guidelines, and instructions of the incorporated reference material as specified in Rule 69L-7.100, F.A.C., prior to making reimbursement decisions.

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