Florida Workers’ Compensation

1 Florida Workers Compensation Health Care Provider Reimbursement Manual Rule , 2015 Edition Florida Workers Compensation Health Care Provider Reimbursement Manual 2015 Edition Page 2 Effective Date: _____ 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 Materials Incorporated by Reference ---------------------------------------- ------------------------- 13 Health Care Provider Use of Codes.

2 Descriptions and Modifiers -------------------------------- 14 Carrier Use of Codes, Descriptions, and References ---------------------------------------- -------- 14 Maintenance and Release of Medical Records ---------------------------------------- --------------- 15 Medical Records for Reimbursement ---------------------------------------- -------------------------- 15 Copies of Medical Records ---------------------------------------- --------------------------------------- 16 General Reimbursement Information ---------------------------------------- ------------------------- 17 Co-Payments ---------------------------------------- ---------------------------------------- --------------- 17 Exceptions to Service Limitations ---------------------------------------- ------------------------------ 20 Disputing Reimbursement ---------------------------------------- --------------------------------------- 21 Classification of an Injured worker s Status.

3 22 CHAPTER 2 MEDICAL SERVICES ---------------------------------------- ------------------------- 24 Anesthesia Services ---------------------------------------- ---------------------------------------- -------- 24 Biofeedback Services ---------------------------------------- ---------------------------------------- ------ 29 Dental Services ---------------------------------------- ---------------------------------------- ------------- 30 Electrodiagnostic Medicine ---------------------------------------- -------------------------------------- 31 Evaluation and Management Services ---------------------------------------- ------------------------- 32 Functional Capacity Evaluations (FCE) ---------------------------------------- ---------------------- 33 Florida Workers Compensation Health Care Provider Reimbursement Manual 2015 Edition Page 3 Effective Date.

4 _____ Home Health Agency Services ---------------------------------------- ---------------------------------- 34 Independent Medical Examinations ---------------------------------------- --------------------------- 35 Failure to Appear for IME ---------------------------------------- -------------------------------------- 36 Consensus Independent Medical Examination ---------------------------------------- -------------- 36 Medications ---------------------------------------- ---------------------------------------- ----------------- 36 Medical Supplies and Home Medical Equipment ---------------------------------------- ----------- 41 Ophthalmologic Services ---------------------------------------- ---------------------------------------- - 42 Permanent Impairment Ratings ---------------------------------------- -------------------------------- 42 Psychiatric and Psychological Services ---------------------------------------- ------------------------ 43 Radiology------------------------------- ---------------------------------------- ----------------------------- 45 Thermography ---------------------------------------- ---------------------------------------- ------------- 46 Transcutaneous Neurostimulators (TNS)

5 ---------------------------------------- --------------------- 46 Physical Medicine and Rehabilitation Services ---------------------------------------- -------------- 47 Acupuncture ---------------------------------------- ---------------------------------------- ---------------- 53 Orthotics and Prosthetics ---------------------------------------- ---------------------------------------- 54 Tests and Measurements ---------------------------------------- ---------------------------------------- - 55 Physical Reconditioning Services ---------------------------------------- ------------------------------- 56 Physical Reconditioning Program ---------------------------------------- ------------------------------ 57 Interdisciplinary Rehabilitation Programs ---------------------------------------- ------------------- 57 Surgical Services ---------------------------------------- ---------------------------------------- ----------- 60 CHAPTER 3 MAXIMUM REIMBURSEMENT ALLOWANCES ----------------------------- 69 CHAPTER 4 BILLING INSTRUCTIONS AND FORMS -------------------------------------- 413 Bill Submission/Filing and Reporting Requirements ---------------------------------------- ----- 413 Form DFS-D5-DWC-9 (CMS-1500) ---------------------------------------- ------------------------- 415 Form DFS-D5-DWC-10 ---------------------------------------- ---------------------------------------- 417 Appendix A Workers Compensation Unique Procedure Codes ------------------------------- 418 Florida Workers Compensation Health Care Provider Reimbursement Manual 2015 EditionPage 4 Effective Date.

6 _____ Appendix B Official Source for References ---------------------------------------- ---------------- 419 Appendix C Medicare Payment Localities (Counties) ---------------------------------------- ---- 422 Appendix D Forms for Medical Billing, Filing and Reporting ---------------------------------- 423 Appendix E Definitions ---------------------------------------- ---------------------------------------- - 424 Florida Workers Compensation Health Care Provider Reimbursement Manual 2015 Edition Page 5 Effective Date: _____ THIS PAGE LEFT INTENTIONALLY BLANK Florida Workers Compensation Health Care Provider Reimbursement Manual 2015 Edition Page 6 Effective Date: _____ Chapter 1 Introduction and Overview Overview Changes to the Manual Notification of approved changes to the Manual will be sent via the Division of Workers Compensation E-Alert system.

7 An update can be an approved change, addition, or correction to the policies. Updates will be available under Manuals on the DWC web site. It is important that health care providers and carriers read the information. Both parties have a responsibility for performing specific duties when billing, reporting, or reimbursing medical services rendered to injured workers. E-Alert System 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 web site to register for our mailing list. Once completed, you shall receive E-Alerts whenever they are provided by the Division. Explanation of the Update Log The health care provider and carrier can use the update log to determine if all the updates to the Manual have been received.

8 Update No. is the year that the update was issued. Effective Date is the date that the update is effective. Instructions File the Manual as instructed. You may wish to retain the prior Manual for billing services prior to the effective date of this Manual or for comparing policy changes. UPDATE NO. EFFECTIVE DATE 2015 TBD Florida Workers Compensation Health Care Provider Reimbursement Manual 2015 Edition Page 7 Effective Date: _____ Chapter 1 Introduction and Overview, continued Overview, continued Preface This Chapter introduces the format used for the Florida Workers Compensation 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, Rule , Florida Administrative Code ( ); Florida Workers Compensation Health Care Provider Reimbursement Manual, Rule , ; and Florida Workers Compensation Reimbursement Manual for Hospitals, Rule , Other Applicable Rules In addition to this Manual, the Florida Workers Compensation Health Care Provider Reimbursement Manual, Rule , , also recognizes the following resource: The Workers Compensation Medical Reimbursement and Utilization Review, Rule Chapter 69L-7, How to Obtain Manual The effective Manual can be obtained free of charge on the DWC web site, under the Provider tab, then click on Reimbursement Manuals.

9 The Manual 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. Florida Workers Compensation Health Care Provider Reimbursement Manual 2015 Edition Page 8 Effective Date: _____ 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 self-insured 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.

10 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 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.