Florida Workers’ Compensation

Florida Workers' Compensation

Health Care Provider Reimbursement Manual Rule 69L-7.020, F.A.C. 2015 Edition

Effective July 1, 2016

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 Manual ------------------------------------------------------------------------------------ 7 Characteristics of the Manual---------------------------------------------------------------------------- 8 Manual Updates -------------------------------------------------------------------------------------------- 9 Identifying New Material --------------------------------------------------------------------------------- 9 Health Care Provider Use of Codes, Descriptions and Modifiers -------------------------------- 14 Carrier Use of Codes, Descriptions, and References------------------------------------------------14 Maintenance and Release of Medical Records ------------------------------------------------------- 15 Medical Records for Reimbursement------------------------------------------------------------------16 Copies of Medical Records-------------------------------------------------------------------------------17 General Reimbursement Information ----------------------------------------------------------------- 18 Co-Payments ----------------------------------------------------------------------------------------------- 18 Exceptions to Service Limitations ---------------------------------------------------------------------- 21 Disputing Reimbursement ------------------------------------------------------------------------------- 22 Classification of an Injured Worker's Status -------------------------------------------------------- 23 CHAPTER 2 MEDICAL SERVICES -------------------------------------------------------- 25 Anesthesia Services----------------------------------------------------------------------------------------25 Biofeedback Services--------------------------------------------------------------------------------------30 Dental Services --------------------------------------------------------------------------------------------- 31 Electrodiagnostic Medicine ------------------------------------------------------------------------------ 32 Evaluation and Management Services-----------------------------------------------------------------33

2015 Edition

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Effective Date: July 1, 2016

Florida Workers' Compensation Health Care Provider Reimbursement Manual Functional Capacity Evaluations (FCE) --------------------------------------------------------------34 Home Health Agency Services -------------------------------------------------------------------------- 35 Independent Medical Examinations ------------------------------------------------------------------- 36 Failure to Appear for IME ------------------------------------------------------------------------------37 Consensus Independent Medical Examination ------------------------------------------------------ 37 Medications ------------------------------------------------------------------------------------------------- 37 Medical Supplies and Home Medical Equipment --------------------------------------------------- 42 Ophthalmologic Services --------------------------------------------------------------------------------- 43 Permanent Impairment Ratings (PIR) ----------------------------------------------------------------43 Psychiatric and Psychological Services----------------------------------------------------------------44 Radiology---------------------------------------------------------------------------------------------------- 46 Thermography --------------------------------------------------------------------------------------------- 47 Transcutaneous Neurostimulators (TNS)-------------------------------------------------------------47 Physical Medicine and Rehabilitation Services ------------------------------------------------------48 Acupuncture ------------------------------------------------------------------------------------------------ 54 Orthotics and Prosthetics --------------------------------------------------------------------------------55 Tests and Measurements --------------------------------------------------------------------------------- 56 Physical Reconditioning Services-----------------------------------------------------------------------57 Physical Reconditioning Program----------------------------------------------------------------------58 Interdisciplinary Rehabilitation Programs -----------------------------------------------------------58 Surgical Services-------------------------------------------------------------------------------------------61

CHAPTER 3 MAXIMUM REIMBURSEMENT ALLOWANCES -------------------- 70

CHAPTER 4 BILLING INSTRUCTIONS AND FORMS ----------------------------- 413 Bill Submission/Filing and Reporting Requirements --------------------------------------------- 413 Form DFS-F5-DWC-9 (CMS-1500) ------------------------------------------------------------------ 415 Form DFS-F5-DWC-10--------------------------------------------------------------------------------- 417

2015 Edition

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Effective Date: July 1, 2016

Florida Workers' Compensation Health Care Provider Reimbursement Manual Appendix A: Workers' Compensation Unique Procedure Codes ------------------------------ 418 Appendix B Official Source for References-------------------------------------------------------- 419 Appendix C Medicare Payment Localities (Counties) ------------------------------------------- 422 Appendix D Forms for Medical Billing, Filing and Reporting---------------------------------- 423 Form Completion Instructions------------------------------------------------------------------------ 423 Appendix E Definitions--------------------------------------------------------------------------------- 424

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Effective Date: July 1, 2016

Florida Workers' Compensation Health Care Provider Reimbursement Manual

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