Florida Workers’ Compensation
Florida Workers' Compensation
Health Care Provider Reimbursement Manual Rule 69L-7.020, F.A.C. 2016 Edition
Effective July 1, 2017
Florida Workers' Compensation Health Care Provider Reimbursement Manual
TABLE OF CONTENTS
CHAPTER 1 INTRODUCTION AND OVERVIEW.................................................... 6
Overview------------------------------------------------------------------------------------------------------- 6 E-Alert System ----------------------------------------------------------------------------------------------- 6 How to Obtain or Purchase Manuals -------------------------------------------------------------------- 7 Characteristics of the Manual----------------------------------------------------------------------------- 8 Identifying New Material ---------------------------------------------------------------------------------- 9 Health Care Provider Use of Codes, Descriptions and Modifiers -------------------------------- 12 Carrier Use of Codes, Descriptions, and References ------------------------------------------------ 12 General Reimbursement Information ------------------------------------------------------------------ 15 Co-Payments------------------------------------------------------------------------------------------------- 15 General Reimbursement Information, continued---------------------------------------------------- 17 Exceptions to Service Limitations ----------------------------------------------------------------------- 18 Disputing Reimbursement -------------------------------------------------------------------------------- 19 Classification of an Injured Worker's Status --------------------------------------------------------- 20
CHAPTER 2 MEDICAL SERVICES........................................................................... 22
Anesthesia Services ----------------------------------------------------------------------------------------- 22 Biofeedback Services --------------------------------------------------------------------------------------- 27 Dental Services ---------------------------------------------------------------------------------------------- 28 Electrodiagnostic Medicine ------------------------------------------------------------------------------- 29 Evaluation and Management Services ----------------------------------------------------------------- 30 Functional Capacity Evaluations (FCE) --------------------------------------------------------------- 31 Home Health Agency Services --------------------------------------------------------------------------- 32
2016 Edition
Page 2
Effective Date: July 1, 2017
Florida Workers' Compensation Health Care Provider Reimbursement Manual
Independent Medical Examinations -------------------------------------------------------------------- 33 Failure to Appear for IME-------------------------------------------------------------------------------- 34 Consensus Independent Medical Examination ------------------------------------------------------- 34 Medications -------------------------------------------------------------------------------------------------- 34 Medical Supplies and Home Medical Equipment ---------------------------------------------------- 39 Ophthalmologic Services ---------------------------------------------------------------------------------- 40 Permanent Impairment Ratings (PIR) ----------------------------------------------------------------- 40 Psychiatric and Psychological Services----------------------------------------------------------------- 41 Radiology ----------------------------------------------------------------------------------------------------- 43 Thermography ---------------------------------------------------------------------------------------------- 44 Physical Medicine and Rehabilitation Services------------------------------------------------------- 45 Acupuncture ------------------------------------------------------------------------------------------------- 51 Orthotics and Prosthetics --------------------------------------------------------------------------------- 52 Tests and Measurements ---------------------------------------------------------------------------------- 53 Physical Reconditioning Services------------------------------------------------------------------------ 54 Physical Reconditioning Program----------------------------------------------------------------------- 55 Chapter 2 Medical Services, continued ---------------------------------------------------------------- 56 Surgical Services -------------------------------------------------------------------------------------------- 59
CHAPTER 3 MAXIMUM REIMBURSEMENT ALLOWANCES .......................... 68
CHAPTER 4 BILLING INSTRUCTIONS AND FORMS ....................................... 410
Bill Submission/Filing and Reporting Requirements --------------------------------------------- 410 Form DFS-F5-DWC-9 (CMS-1500)------------------------------------------------------------------- 412 Form DFS-F5-DWC-10---------------------------------------------------------------------------------- 414
2016 Edition
Page 3
Effective Date: July 1, 2017
Florida Workers' Compensation Health Care Provider Reimbursement Manual
APPENDIX A: WORKERS' COMPENSATION UNIQUE PROCEDURE CODES ......................................................................................................................................... 415 APPENDIX B OFFICIAL SOURCE FOR REFERENCES.................................... 416 APPENDIX C MEDICARE PAYMENT LOCALITIES (COUNTIES) ................ 419 APPENDIX D FORMS................................................................................................ 420 APPENDIX E DEFINITIONS..................................................................................... 421
2016 Edition
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Effective Date: July 1, 2017
Florida Workers' Compensation Health Care Provider Reimbursement Manual
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2016 Edition
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