Florida Workers Compensation

Health Care Provider Reimbursement Manual

Rule 69L-7.020, F.A.C.

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, 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 Workers Status -------------------------------------------------------- 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: ____________

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) ------------------------------------------------------------- 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 Edition Page 4 Effective Date: ____________

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. 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.

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

http://www.myfloridacfo.com/WC/publications.htmlhttp://www.myfloridacfo.com/division/wc/

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 69L-7.100, Florida

Administrative Code (F.A.C.);

Florida Workers Compensation Health Care Provider Reimbursement Manual, Rule 69L-7.020, F.A.C.