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Good Morning
8:33:11 AM CDT
Thursday, April 24, 2014

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Billing/Fee Schedule
March 2014
H-wave Electrical Stimulation Not Covered


WSI does not cover H-wave electrical stimulation, as it is investigational and experimental.

There is insufficient evidence to show the H-wave stimulation is more effective than transcutaneous electrical nerve stimulation (TENS). Additionally, there are no quality studies evaluating H-wave stimulation for the treatment of acute, subacute or chronic pain syndromes.

If you have questions about this article, please send an email to wsipr@nd.gov.

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March, 2014
Evaluation & Management Documentation


Effective with dates of service beginning May 1, 2014, WSI will adopt the guidelines highlighted below in the auditing of Evaluation and Management (E/M) documentation.

History Section
  • History of Present Illness: If applicable, documentation must identify the chronic conditions; stating three chronic conditions is not sufficient.
  • Review of Systems: A descriptive response is required for any system with a positive or pertinent negative response; stating negative, un-remarkable, non-remarkable, or noncontributory is not sufficient for pertinent negative responses.
  • Past Family Social History: A descriptive response is required for PFSH; stating not on file, noncontributory, negative is not sufficient.

Exam Section
  • A description response is required for abnormal and pertinent negative findings; stating abnormal, negative, un-remarkable, non-remarkable or noncontributory is not sufficient.

The E/M Documentation Guidelines outlines all of the necessary elements of documentation used in the auditing of bills.

If you have questions about this article, please send an email to wsipr@nd.gov.

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Revised February 2014
Originally published October 2013
Billing of Independent Exercise Programs (IEP)


The following information provides clarification on the billing, reimbursement and prior authorization of Independent Exercise Programs (IEP).

WSI billing requirements include the following:
  • Utilization of WSI specific procedure code, W0555
  • Submission of charges on a CMS 1500, UB-04 or voucher
  • Submission of billed charges in increments (i.e. for one month - 1/1/14 to 1/31/14)

An IEP will be reimbursed at the usual and customary rate and require prior approval by completing the IEP Request Form C59a.

If you have questions about this article, please send an email to wsipr@nd.gov.

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February 2014
Billing WSI when Medicare is the Secondary Payer

WSI has identified healthcare providers billing services to Medicare when WSI is the primary payer.

If an injured worker is a Medicare recipient and has a work related injury, WSI should be the primary payer. Medicare regulations require all entities, determine the beneficiary's primary insurance coverage, and then bill the appropriate payer.

Providers are required to wait for prompt payment from WSI prior to billing Medicare. Medicare defines prompt payment as120 days after WSI’s receipt of the bill. In the absence of prompt payment from WSI, providers must wait 120 days from the date of service to bill Medicare. For additional information on the MSP provision, visit www.cms.gov

If you have questions about this article, please send an email to wsipr@nd.gov.

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Revised February 2014
Originally published January 2014
2014 Outpatient Hospital Fee Schedule Changes


This article highlights a few significant changes in the 2014 Outpatient Hospital Fee Schedule regarding Evaluation & Management and Lab codes.

Evaluation & Management Codes:
Evaluation & Management codes (99201-99215) changed to a B Status Indicator, denoting these services are not reimbursable. The alternate code providers need to bill is G0463.

Lab Codes:
Reimbursement of Lab codes with an N Status Indicator are packaged into payment for other services provided during the encounter.

WSI reimburses for these lab codes under the following guidelines:
  • Hospital receives a specimen only and the patient does not present to the hospital
  • Patient presents to the hospital; however, lab tests are the only services provided during the encounter
  • Lab tests are unrelated to the reason the patient is presenting to the hospital and ordered by a physician other than the physician providing other services on the same date

In these scenarios, the hospital should bill the lab charges with the bill type of 141 to indicate the charges are not part of other procedures the patient has received.

If you have questions about this article, please send an email to wsipr@nd.gov.

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January 2014
Billing of Hearing Aids and Related Services

The following information provides clarification on reimbursement and prior authorization for hearing aids and associated services.

WSI reimbursement methodology:
  • If there is a fee schedule amount listed, the service is reimbursed accordingly.
  • If U&C is indicated on the fee schedule, the service is reimbursed according to the 50th percentile of the usual, customary and reasonable rate (UCR) of the geographic area.

Providers should obtain prior authorization from the claims adjuster before dispensing hearing aids. Replacement hearing aids are covered when medically necessary and approved by the claims adjuster. Other associated covered costs may include dispensing fee, batteries and hearing aid exam. Charges should be billed with appropriate HCPCS codes on a CMS 1500.

If you have questions about this article, please send an email to wsipr@nd.gov.

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December 2013
Revised Workability Assessment Program Criteria

In January 2013, WSI issued a Provider Bulletin detailing criteria for the workability assessment program. Based on provider feedback, the following are new criteria for a workability assessment with dates of service after January 1, 2014.

Workability Assessment Criteria
  • Allowed one assessment every 2 weeks, without prior authorization
  • Scheduled within 2 days of a physician visit to assist providers in determining capabilities
    • Utilized to accurately determine capabilities of the injured worker
    • Warranted only if the injury results in job restrictions
  • Required separate report, identifiable as the workability report, even if the assessment is completed on the same day as other therapy
  • Billed using CPT® code 97750
  • Allowed maximum of 3 units (45 minutes)
If you have questions about this article, please send an email to wsipr@nd.gov.

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December 2013
Updated Fee Schedule effective January 1, 2014

Effective January 1, 2014, WSI will implement the following fee schedule changes. Click here to access the full fee schedules.

  1. Ambulance fee schedule update is based on the CPI-U
    • Reimbursement increased by 1.8%
    • In addition to the to the CPI-U increase, a one-time increase will be incorporated.
      • Ground Ambulance 10% increase (mileage and base rate)
      • Air Ambulance 15% increase (mileage and base rate)
  2. Ambulatory Surgical Center fee schedule update is the Market Basket for hospital services with adjustments for anticipated ASC weight changes
    • ASCs billing for device-intensive procedures
      • Report a single line item charge that includes both the charges associated with the service and the implantable device.
    • WSI will reimburse for services in the Medicine Section of the AMA CPT® code set if listed on Medicare’s published list of covered ASC services.
    • Conversion factor increased by 2.5% to $97.48
  3. Anesthesia fee schedule
    • Conversion factor increased 1.7% to $55.68
  4. Clinic Laboratory fee schedule is 250% of North Dakota’s Medicare Laboratory fee schedule
  5. Dental fee schedule reflects a consistent payment for providers in all locations
    • Usual & Customary (UCR) module at the 70th percentile will be used
  6. Durable Medical Equipment fee schedule is 120% of North Dakota’s Medicare schedule
  7. Home Health fee schedule update is the Market Basket for Home Health services
    • Increase is 2.3% rounded to the nearest 50 cents
  8. Inpatient Hospital fee schedule update is a blended (operating and capital) Market Basket increases for hospital services with adjustments for anticipated DRG weight and coding changes
    • Market Basket base rate increased by 2.42% to $8,470.00
    • The outlier threshold for 2014 is $53,000
  9. Medicine fee schedule uses the Resource Based Relative Values System (RBRVS) Relative Value Unit (RVU) established by CMS. All services have a single conversion factor
    • Includes fee schedules for Chiropractic, E&M, Pathology, Medicine, PT and OT, Radiology and Surgery codes
    • CPT code changes from the American Medical Association (AMA) have been adopted
    • In following Medicare’s requirements, WSI will not recognize consult codes as valid codes.
    • Conversion factor increased by 1.7% to $65.28
  10. Outpatient Hospital fee schedule update is the Market Basket for hospital services with adjustments for anticipated APC weight changes
    • Conversion factor increased by 2.5% to $123.55

If you have questions about this article, please send an email to wsipr@nd.gov.

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November 2013
New Reason Code 226: Managed Care – Service Not Medically Necessary...

Effective November 15, 2013, a new Reason Code (RC) 226: Managed Care – Service Not Medically Necessary will be used to identify the denial or reduction of charges for services that are determined to be not medically necessary to treat or diagnose a compensable work injury.

Providers may notice RC 226 used on charges typically denied as unrelated with reason codes 11: Liability Determination – Service Partially Unrelated to Claim or 12: Audit Liability Determination – Unrelated Service. To view the full description of RC 226 click here.

The provider will receive a letter indicating the denial and outlining the appeal process. The provider has 30 days from the date of the letter to appeal the denial utilizing the Medical Services Dispute Resolution Request (M2) form.

If you have questions about this article, please send an email to wsipr@nd.gov.

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October 2013
Billing of Independent Exercise Programs (IEP)

Facilities should use the WSI specific procedure code, W0555, when billing for Independent Exercise Programs (IEP). Providers must submit charges for the W0555 on a CMS 1500, UB-04 or invoice.

An IEP will be reimbursed at the usual and customary rate and require prior approval by completing the IEP Request Form C59a.

If you have questions about this article, please send an email to wsipr@nd.gov.

...Read More >>
July 2013
Expanded W0200 Code

Effective July 1, 2013 the WSI unique billing code W0200 has expanded to include reimbursement when an employer attends a medical appointment to discuss the injured workers capabilities. Previously, only phone calls made to an employer by a provider were reimbursable.

Documentation in the office notes when billing the W0200 code must include:
  • Name of employer, name and title of employer representative attending the appointment (e.g. ABC Company; John Smith, Safety Consultant)
  • Conversation with the employer representative regarding the restrictions, job tasks, job description or availability of transitional work for the injured worker
  • Time spent for this part of the visit

The following services are not billable:
  • Conversation between ancillary medical staff and employer representative
  • Conversation less than five (5) minutes

Time associated with the activities used to meet the criteria for the W0200 code is not include in the time used for reporting the E/M level.

If you have questions about this article, please send an email to wsipr@nd.gov.

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June 2013
New Psychotherapy Codes for 2013

In January, 2013, the AMA issued major CPT Code changes to many diagnostic and therapeutic services found in the Psychiatry section. One of the most notable changes includes the replacement of codes specifying durations of psychotherapy face-to-face services with the patient and/or family member. The patient must be present for all or some of the service.

When billing, report the code that reflects the range inclusive of the actual time:
  • Less than 16 minutes, psychotherapy should not be reported
  • 16-37 minutes – 90832
  • 38-52 minutes – 90834
  • 53 or more minutes – 90837
  • More than 68 minutes – 90837 with a Prolonged Services Code (99354-99357); cannot be reported with E/M services

There are also new add-on codes (90833, 90836 and 90838) to report when E/M services are on the same day as a psychotherapy service. To report the new codes:
  • E/M and psychotherapy services must be significant and separately identifiable
  • Type and level of E/M service is selected first
  • Time associated with activities used to meet criteria for the E/M service is not included in the time used for reporting the psychotherapy service.
    • Time may not be used as the basis of E/M code selection
    • Prolonged services may not be reported if psychotherapy is reported with an E/M services.
  • Separate diagnosis is not required for E/M and psychotherapy services on the same date
If you have questions about this article, please send an email to wsipr@nd.gov.

...Read More >>
May 2013
Blood Born Pathogen Exposure Claims
Blood born pathogen exposure claims need to be billed with modifier 22 added to the charges for the source patient.

WSI will cover testing of the source patient when an employee has an injury resulting from a needle stick. Providers should submit the charges and the test results from both the injured worker and the source patient. The charges should be billed separately, with the charges from the source patient identified with modifier 22. The billed charges and the test results from the source patient should also include the claim number of the injured worker and “source patient” in place of the name of the person. The charges for the injured worker would be billed in the normal format, without the modifier, and with the patient’s name and claim number.

If you have questions about this article, please send an email to wsipr@nd.gov.

...Read More >>
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