Why
do some codes have fees set for them and others don't?
What
does POC76 mean?
By law, the fee schedule was created using actual bills from
August 1, 2002 through August 1, 2004. If a code did not exist
during that time, or if there were not enough bills with which
to calculate a fee, the POC76 was used by default.
"POC"
stands for "percentage of charge." "POC76"
means you should pay 76% of the charged amount.
All
new codes that have been added since the fee schedule was
created should be paid at 76% of the charged amount.
What
is a geozip?
A
geozip is defined as the first three digits of the zip code
in Illinois where the medical treatment was provided.
If you receive medical care in the zip code 60601, for example,
the fees would appear in the geozip 606. Click
here to see a list of some of the cities in each Illinois
geozip.
What
is a conversion factor?
A conversion factor is a dollar amount used to determine the
amount of reimbursement for most anesthesia services. The
conversion factor is multiplied by time units, base value
units, modifier units, and qualifying circumstances units.
Calculating the correct fee schedule amount can be determined
by consulting the Instructions and Guidelines, ASA Relative
Value Guide, and the AMA CPT.
What
is a modifier?
Modifiers are two-digit numeric or alpha attachments to CPT
codes that indicate that a service was altered in some way from
the stated CPT description—without actually changing the
basic CPT definition.
Modifiers
can indicate, among other things, that
a)
the procedure was either professional or technical;
b) the procedure was complicated or unusual;
c) the procedure was bilateral;
d) an adjunctive service was performed; or
e) a procedure was performed by more than one person.
Some
modifiers may affect reimbursement—consult the Instructions
and Guidelines for further details.
How
can I find out which hospitals are designated as Level I &
II trauma centers?
Click
here for the list.
What
facilities are licensed as Ambulatory Surgical Treatment Centers
(ASTCs)?
The Illinois
Department of Public Health has a
list of licensed ASTCS, as well as the ASTC
application form and other information on its website.
Note that the fee schedule only recognizes ASTCs licensed
by the IDPH (see Section 7110.90(h)(1)(A) of the rules).
Where
can I find the NCCI manual for bundling edit information?
The
IWCC adopted the National
Correct Coding Initiative Coding Policy Manual as the
review standard for bundling edits:
Ch.
1: General Correct Coding Policies
Ch. 2: Anesthesia Services
(CPT codes 00000-09999)
Ch. 3: Surgery:
Integumentary System (CPT codes 10000-19999)
Ch. 4: Surgery: Musculoskeletal
System (CPT codes 20000-29999)
Ch. 5: Surgery: Respiratory,
Cardiovascular, Hemic, and Lymphatic Systems (CPT codes 30000-39999)
Ch. 6: Surgery:
Digestive System (CPT codes 40000-49999)
Ch. 7: Surgery:
Urinary, Male Genital, Female Genital, Maternity Care and
Delivery Systems (CPT codes 50000-59999)
Ch. 8: Surgery:
Endocrine, Nervous, Eye and Ocular Adnexa, Auditory Systems
(CPT codes 60000-69999)
Ch. 9: Radiology Services
(CPT codes 70000-79999)
Ch. 10: Pathology and Laboratory
Services (CPT codes 80000-89999)
Ch. 11: Medicine, Evaluation
and Management Services (CPT codes 90000-99999)
Ch. 12: Supplemental
Services (HCPCS Level II codes A0000-V9999)
Ch. 13: Category III Codes
(CPT codes 0001T-0099T)
Where
can I find the "Payment Guide to Global Days?"
Click
here for a copy.
How
are the fees adjusted each year?
According to Section 8.2(a) of the Act, on January 1 of each
year the IWCC adjusts all the fees by the percentage change
in the Consumer Price Index-All Urban Consumers, All Items
(1982-84=100) for the 12-month period ending August 31 of
the previous year.
Adjustments
to Medical Fees |
February
1, 2006 |
4.90% |
January
1, 2007 |
3.80% |
| January
1, 2008 |
1.97% |
| January
1, 2009 |
5.37% |
Does
the fee schedule apply to medical treatments before February
1, 2006?
No. The schedule only covers treatments that are covered
under the Act and are provided on or after 2/1/06.
The date of injury is not relevant. Before 2/1/06,
payment was at the usual and customary rate.
Are
there any services not subject to the fee schedule?
Yes. The fee schedule covers only those areas of medical treatment
specifically listed on the IWCC website. The fee schedule
does not apply, for example, to skilled nursing facilities
or pharmacy. These treatments should be paid at the usual
and customary rate.
To the extent that there are fees listed for home health services,
outpatient renal dialysis, or psychiatric hospitals (freestanding
or dedicated psychiatric units in acute care hospitals) in
the HCPCS and CPT professional services fee schedules, these
fees should be applied.
All
new codes that have been added since the fee schedule was
created should be paid at 76% of the charged amount.
How should pharmacy drugs be paid?
The fee schedule does not apply to pharmacy prescriptions.
Prescriptions should be paid at the usual and customary rate.
The law and rules make no mention of what the usual and customary
rate is. No formula was adopted. If there is a dispute, the
parties would take the issue before an arbitrator.
There are some general HCPCS codes on the fee schedule (e.g.,
J3490: unclassified drug) that show a fee or POC76 (i.e.,
pay 76% of charge). Some providers use these codes for
prescription bills and claim that payment should be at that
fee or at 76% of charge. This is not correct. People should
not use HCPCS codes to side-step the fact that Illinois does
not have a pharmacy fee schedule.
Does
the fee schedule cover medical reports? What about copying fees?
A provider may not charge a fee for writing a standard report
that is generated in the normal course of treatment (e.g.,
office visit documentation). If the provider writes a special
report that is unusual or outside the standard reporting forms,
then an additional fee may be charged.
The fee schedule does not set a fee for the usual code that
identifies a special medical report, CPT 99080, nor does it
show the default of POC 76. Whenever the fee schedule does
not cover a procedure, the usual and customary rate would
apply.
The fee schedule does not cover fees for copying medical reports.
The usual and customary rate would apply.
If
medical records are subpoenaed, there is no per-page copying
fee allowed. The law and rules provide only for mileage and
a mandatory $20 fee. (See Section 16 of act; Section 7030.50
of rules; Circuit Courts Act)
Is
there a set fee for Section 12 medical exams (also known as
independent medical exams)?
No.
An evaluative exam conducted at the employer's request is
not considered treatment and is not covered under the fee
schedule.
Does
the Illinois fee schedule apply if the worker/employer/medical
provider is in another state?
The
defining factor is where the worker filed the workers' compensation
claim. If the worker filed the claim in Illinois, then Illinois
law applies.
For
example, if a worker filed a claim in Illinois and received
treatment in another state, IL law would apply. IL law provides
that out-of-state treatment should be paid at the greater
of 76% of the charged amount or that state's fee schedule
(if that state has a schedule).
If
the worker filed a claim in another state, the law in that
state would govern how medical treatment shall be paid.
Does
the Illinois fee schedule address missed appointments?
No. The fee schedule only applies to services actually rendered
in the treatment of an injured worker.
Should we pay medical bills according to our contract
or the fee schedule?
If
there is a contract for medical services, the contract prevails
over the fee schedule.
If
there is not a contract, Sections 8(a) and 8.2 require that
the employer shall pay the lesser of the provider's actual charges
or the amount set by the fee schedule.
The
Workers' Compensation Medical Fee Advisory Board has drafted
a statement to clarify
the law (Section 8.2(f)) and rules (Section 7110.90(d)) regarding
the precedence of an existing contract over the fee schedule.
Is
balance billing allowed?
The
term "balance billing" refers to an attempt by a
medical provider to get an injured worker to pay the unpaid
balance of a medical bill. Effective
July 20, 2005, there is a prohibition on balance billing.
Section 8.2(e) of the Act provides a provider may seek payment
of the actual charges from the employee if the employer notifies
a provider that it does not consider the illness or injury
to be compensable. If an employer notifies a provider that
it will pay only a portion of a bill, the provider may seek
payment of the unpaid portion from the employee up to the
lesser of the actual charge, the negotiated rate, or the rate
in the fee schedule.
If an employee informs the provider that a claim is on file
at the Commission, the provider must cease all efforts to collect
payment from the employee. Any statute of limitations or statute
of repose applicable to the provider's efforts to collect from
the employee is tolled from the date that the employee files
the application with the Commission until the date that the
provider is permitted to resume collection.
While the claim at the Commission is pending, the provider may
mail the employee reminders that the employee will be responsible
for payment of the bill when the provider is able to resume
collection efforts. The provider may request information about
the Commission claim and if the employee fails to respond or
provide the information within 90 days, the provider is entitled
to resume collection efforts and the employee is responsible
for payment of the bills. The reminders shall not be provided
to any credit agency.
Upon final award or settlement, a provider may resume efforts
to collect payment from the employee and the employee shall
be responsible for payment of any outstanding bills plus interest
awarded. If the service is found compensable, the provider shall
not require a payment rate, excluding interest, greater than
the lesser of the actual charge or payment level set by the
Commission in the fee schedule. The employee is responsible
for payment for services found not covered or compensable unless
agreed otherwise by the provider and employee. Services not
covered or not compensable are not subject to the fee schedule.
How
do I pay bills where there are professional and technical
components (PC/TC)?
In
radiology, pathology and laboratory, and physical medicine,
a doctor may bill for the professional component (modifier
PC or 26) and a facility may bill for the technical component
(modifier TC). A technician may take a x-ray, for example,
and a radiologist would read it.
Most
of the time, each component is billed separately. When possible,
we calculated a fee for each component. If a dollar amount
appears under the appropriate PC/TC column, that represents
the maximum payment for that component.
If
we didn’t have enough data to calculate a fee, by law
the schedule defaults to POC76, which means to pay 76% of
the charged amount. A bill for either component should be
paid at 76%.
For example, the maximum 2008 fee for a chest scan (71275)
in geozip 600 is $298.96 for the professional component and
$1,195.82 for the technical component. In geozip 609, the
default of POC76 is used. If a component is billed separately,
it should be paid at 76% of the charged amount. The PC/TC
columns, which show that the bill should be split (e.g., 20/80),
are relevant only if both components are billed at the same
time.
How
are healthcare professionals paid in hospital settings?
All healthcare professionals who perform services in a hospital
setting and bill for these services using their own tax ID
number on a separate claim form are subject to the Professional
Services and/or HCPCS fee schedule. While these services are
provided in a hospital setting and not a physician’s
office, the application of the fee schedule will be the same
as though these services had been provided in the physician’s
office. In other words, there is no site-of-service adjustment.
Where professional services are performed in a hospital setting
(e.g., a radiologist reading an x-ray, or CRNA services) and
billed by the hospital using its tax ID number for
these services, then the professional services fee schedule
will not apply; rather, the amount paid will be 76% of the
charged amount.
If anesthesia is given for only part of a 15-minute increment,
how should this be billed?
The standard practice is to round up to the next unit. If
anesthesia was administered for 7 minutes, for example, you
would bill one unit. If anesthesia is administered for 63
minutes, five units would be billed, etc.
Should
a medical provider send bills to the employer or the payor?
Throughout the Illinois Workers' Compensation Act, there are
many references to the employer where, in practice, the payor
(an insurer or third party administrator) assumes responsibility
for the employer. Section 6(b), for example, says the
employer shall file accident reports, but the payor usually
files them on the employer's behalf. The payor is understood
to stand in the shoes of the employer.
Nothing
in the new law changes this. A safe policy, therefore, would
be for a provider to submit the bill to the payor, when known.
Another option would be to submit the bill to both the employer
and the payor.
If
the payor is supposed to pay a percentage of the charged amount,
can it require the medical provider to submit a copy of the
invoice?
No.
The schedule only refers to the charged amount.
The rules do require hospitals to follow their chargemaster.
Payors may contact a hospital's financial/contract services
staff to check an amount.
What
can I do if the payor won’t pay me correctly?
There are four options:
| 1.
|
The
medical provider can charge interest on unpaid amounts.
Payments are due within 60 days of the date the
payor receives substantially all the information needed
to adjudicate a bill. Unpaid bills accrue interest of
1% per month, under new Section 8.2(d). Proceed
as you would with any other unpaid bill by submitting
a statement for accrued interest as part of the overall
bill. |
| 2.
|
The
worker can request a hearing regarding unpaid medical bills,
and file a petition for penalties and/or attorneys' fees
for delay or nonpayment of medical bills. An employer
may have to pay the worker's attorney fees under Section
16; Section 19(k) penalties can run up to 50% of the amount
due; Section 19(l) penalties can run up to $30 per day,
with a maximum of $10,000. These penalties and fees are
payable to the worker. |
| 3.
|
If
the dispute involves issues relating to terms and conditions
outlined within the provider agreement, including negotiated
discounts between a health care provider and a payor,
the Illinois Division of Insurance may be able to help.
Contact David Grant, Health Care Coordinator, Illinois
Department of Financial and Professional Regulation, Division
of Insurance, Managed Care Unit, at 217/782-6369 or dave.grant@illinois.gov. |
| 4.
|
If
a person misrepresents the facts for the purpose of denying
or obtaining payment, he or she may be guilty of workers'
compensation fraud. Section 25.5 provides that fraud
is a Class 4 felony. Any person or organization found
to have violated this provision is subject to criminal
penalties and can be ordered to pay restitution and fines.
If you think fraud may be involved, contact Francis "Buzz"
Walsh, manager of the WC Fraud unit at the Illinois Division
of Insurance (toll-free 877/923-8648 or francis.walsh@illinois.gov).
|
Is
the interest on medical bills owed if the claim is disputed
for valid reasons but later determined to be compensable?
Yes, provided the requirements of Section 8.2(d) are met.
Must
bills be submitted on certain forms?
The rules state that hospital inpatient services should be
billed on the UB-04/CMS 1450 claim form. Otherwise, the fee
schedule does not dictate the type of billing forms used.
(Our act and rules do not require the latest CMS-1500.)
In the interest of facilitating transactions, we do encourage
providers to use standard billing forms.
Does
the attorney have to itemize each medical provider's bill
to fit within the fee schedule? For example, instead of listing
the charge for an office visit, should he or she list the
fee schedule amount?
If bills are not paid and the case goes to arbitration, attorneys
should submit the bills as they are, and then, in the proposed
decision, identify the amount to be awarded. If the bill is
less than the fee schedule amount, the bill is awarded at
100% of the charge. If the bill is more than the fee schedule
amount, it is awarded at the fee schedule amount.
Can
you tell me if I am calculating a bill correctly?
We can provide general answers, as listed on this web page,
but we do not have the resources to address individual calculations.
If
parties cannot reach agreement over a bill, the worker would
request a hearing before an arbitrator regarding unpaid medical
bills.
Did
the IWCC adopt the new MS-DRGs?
No. By law, the fee schedule is based on historical charges
and it is not a simple matter to change codes. We are working
to establish a MS-DRG fee schedule by June 30, 2009.
Providers
should continue to bill, and payors should continue to pay,
under the current DRG codes in the fee schedule. If providers
cannot bill using the old DRG codes, we encourage people to
work together to translate the bill until we can update our
fee schedule. DRG codes can be translated into MS-DRG codes;
a crosswalk, CMS Grouper Version 24.0,
can assist in this process.
Click
here if you would like to be added to our email news list
to hear of fee schedule developments.
How
should the payor handle a bill with incorrect codes? Can the
payor alter the codes on a bill? Does the fee schedule allow
for down-coding?
The Instructions and Guidelines direct users to reference
materials incorporated into the fee schedule (e.g., Correct
Coding Initiative, AMA’s CPT). To the extent that a
medical bill is submitted in a manner inconsistent with these
documents, then a bill can be questioned. The payor should
contact the provider and try to resolve such issues. If the
parties cannot resolve the issue, the employer or worker may
file a petition for a hearing before an arbitrator regarding
unpaid medical bills.
How
is a bill with pass-through charges handled?
First subtract the pass-through charges (also known as revenue
code charges) from the bill, then apply the fee schedule.
If, for example, a bill comes in for $50,000 with $10,000
in pass-through charges, apply the remaining $40,000 to the
fee schedule amount, and pay the lesser of the $40,000 or
the fee schedule amount. Then pay 65% of the pass-through
charges ($6,500 in this example).
Should pass-through charges or outlier charges be billed
separately from regular services?
You should clearly identify the different charges, but separate
bills are not necessary.
How
do I apply the modifiers to an out-of-state treatment bill?
First determine if there is a contract. If there is, you follow
that.
If there's no contract, determine if the other state has a
fee schedule and, if so, determine if it would pay more than
76% of the bill. If it does, you follow that state's fee schedule.
Otherwise, pay 76% of charges, subject to the other instructions
and guidelines. First apply the modifiers, then apply the
76%.
For example, if an out-of-state provider (with no contract
and no fee schedule in that state) bills $5,000 for a procedure
with the modifier 22, the Illinois fee schedule would call
for payment at 125% X $5,000 = $6,250 X 76% = $4,750.
What
do the codes NU, RR, and UE mean?
Fees for durable medical equipment vary, depending on whether
the equipment is new, old, or rented. According to the HCPCS
manual, NU = new equipment; RR = rental; and UE = used equipment.
How
can I find out what the base value is for an anesthesia procedure?
The fee schedule relies on the "2006 Relative Value Guide"
published by the American Society of Anesthesiologists (847/825-5586;
cost $25). Surgical procedures are assigned a base value,
e.g., 3 units for a closed procedure on a wrist, 4 units for
a closed procedure on a shoulder.
Do
the fees represent time units?
If the description of a code includes a time increment, then
the fee schedule incorporates that time increment. If the
description does not contain a time increment, then the fee
schedule amount reflects reimbursement for an episode as is
generally accepted in Illinois.
When
an ambulance travels from one geozip to another, which one
should count for billing?
The most common and universally accepted practice is to use
the geozip of the place where the patient was picked up.
How
does the new law on utilization review affect the process at
the IWCC?
Section
8.7 provides that if an employer chooses to conduct utilization
review, it must use individuals who are registered with the
Illinois
Department of Financial and Professional Regulation and
who certify compliance with URAC
standards for Workers' Compensation Utilization Management
(WCUM) or Health Utilization Management (HUM). Click
here to read the IDFPR's UR rules.
At
the IDFPR, Kelly
Reim (217/558-2309) coordinates the processing of the
UR applications. Click
here for a list of approved UR providers.
When
making determinations concerning the reasonableness and necessity
of medical bills or treatment, the IWCC will consider UR findings
along with all other evidence. If an employer follows a WCUM
or HUM URAC standard when refusing to pay for or authorize
medical treatment, there shall be a rebuttable presumption
that the employer should not be assessed penalties under Section
19(k).
What
do I need to know about Workers' Comp Medicare Set-Aside Arrangements?
All parties in a workers' compensation (wc) case are responsible
under the Medicare secondary payer laws to protect Medicare's
interests when resolving wc cases that include future medical
expenses.
Medicare
recommends parties draft a Workers' Compensation Medicare
Set-aside Arrangement (WCMSA), which allocates a portion of
the wc settlement for future medical expenses.
The
amount of the set-aside is determined on a case-by-case basis
and should be reviewed by the Centers for Medicare and Medicaid
Services (CMS), in the following situations:
The claimant is currently a Medicare beneficiary and the total
settlement amount is greater than $25,000; or
The claimant has a "reasonable expectation" of Medicare
enrollment within 30 months of the settlement date and the
anticipated total settlement amount for future medical expenses
and disability/lost wages over the life or duration of the
settlement agreement is expected to be greater than $250,000.
Once the CMS-determined set-aside amount is exhausted and
accurately accounted for to CMS, Medicare will pay as primary
payer for future Medicare-covered expenses related to the
wc injury.
To address the administrative problems that parties face while
awaiting set-aside approval, former Chairman Ruth issued a
memo directing cases be continued
during the approval period.
For more info, go to the Medicare
website.
How
does HIPAA affect workers' compensation?
The U.S. Department of Health and Human Services, Office of
Civil Rights (OCR), administers the Health Insurance Portability
and Accountability Act (HIPAA). It has issued guidelines
that indicate that covered providers may disclose health information
to workers' compensation insurers, state administrators, employers,
and other entities involved in the w.c. system, to the extent
disclosure is necessary to comply with, or is required by,
state law, or to obtain payment.
The guidelines include a number of frequently asked questions.
For more information, please contact the U.S.
Department of Health and Human Services.
