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
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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
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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
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Chapter 1 Introduction and Overview 0B
Overview
4B
Changes to the Manual
Reimbursement Manuals will be available under the `Reimbursement Manuals' section on the DWC website.
It is important that health care providers (HCPs) and carriers read the updated material in the Manual. Both parties have a responsibility for performing specific duties when billing, reporting, or reimbursing medical services rendered to injured workers.
E-Alert System
5B
The Division of Workers' Compensation has an electronic alert system to notify subscribers of upcoming news impacting the Workers' Compensation industry, dates of public meetings and workshops.
To subscribe to the "E-Alerts", please go to the DWC website. Look for the box entitled "Register". Once registered, you will receive E-Alerts whenever they are provided by the Division.
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Chapter 1 Introduction and Overview, continued
Overview, continued
Preface
This Chapter introduces the format used for the Florida Workers' Compensation Health Care Provider Reimbursement Manual and tells the reader how to use the Manual.
Background
There are 3 types of Workers' Compensation Manuals:
Florida Workers' Compensation Reimbursement Manual for Ambulatory Surgical Centers, [ASC Manual], Rule 69L-7.100, Florida Administrative Code (F.A.C.);
Florida Workers' Compensation Health Care Provider Reimbursement Manual, [HCP RM], Rule 69L-7.020, F.A.C.; and
Florida Workers' Compensation Reimbursement Manual for Hospitals, [Hospital Manual], Rule 69L-7.501, F.A.C.
Other Applicable Rules
In addition to this Manual, the Florida Workers' Compensation Health Care Provider Reimbursement Manual, Rule 69L-7.020, F.A.C., also recognizes the following resource:
1. The Workers' Compensation Medical Reimbursement and Utilization Review, Rule Chapter 69L-7, F.A.C., and
2. Selected Materials Incorporated by Reference For Use In Workers' Compensation, Rule Chapter 69L-8, F.A.C.
How to Obtain or
6B
Purchase Manuals
This Manual can be obtained free of charge on the DWC website, under `Reimbursement Manuals' or may also be purchased in hard copy from the Department of Financial Services, Document Processing Section, at 200 East Gaines Street, Tallahassee, Florida 32399-0311.
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Chapter 1 Introduction and Overview, continued
Purpose
The purpose of the Florida Workers' Compensation Health Care Provider Reimbursement Manual (FL WC HCPRM) is to furnish health care providers with the policies and procedures needed to report services rendered to injured workers, and to file medical bills to carriers or selfinsured employers for reimbursement of services rendered. The FL WC HCPRM also provides carriers or self-insured employers the schedule of maximum reimbursement allowances approved by the Three-Member Panel for reimbursing health care providers for medically necessary care and treatment.
The Manual provides descriptions and instructions on how and when to complete forms and other documentation that will assist in the medical bill filing process, as well as how to apply the reimbursement methodology for the schedule of Maximum Reimbursement Allowances (MRAs) to assist in the proper reimbursement of billed services.
Characteristics of the Manual
7B
Format
The format styles used in the Manual represent a concise and consistent way of displaying complex, technical material.
Information Block
Information Blocks replace the traditional paragraph and may consist of one or more paragraphs about a portion of a subject. Blocks are separated by horizontal lines.
Each block is identified or named with a label.
Label
Labels or names are located in the left margin of each information block. The labels identify the content of the block in order to facilitate scanning and locating information quickly.
Note:
Note: is used most frequently to refer the user to pertinent material located elsewhere in the Manual, related Rules, specific statutory authority or to exceptions and limitations to a policy.
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