DATE:    February 28, 2003

TO:        All Interested Parties

FROM:   Health Care Services Division

RE:        Health Care Services Rules - 2003 Updates

The 2003 updates to the Health Care Services Rules and Manual (fees) are effective on March 4, 2003. The rules and fee manual will be placed on the bureau website after the effective date. An order form is available if you would like the rules and fee manual in hard copy.

SUMMARY OF RULE CHANGES FOR 2003

• Rule 104: Rule title changed to include reimbursement to a health insurer. Adds language indicating that requests for the repayment need not be submitted on a medical claim form.
• Rule 105: Adds language preventing the injured worker from being billed for incurred late fees.
• Rule 106: Updates cites for using CPT®.
• Rule 107: Updates to the 2003 source documents. Deletes the 1999 source document for relative values.
• Rule 108: Adds a definition for an industrial medicine clinic.
• Rule 116: Adds language (sub 1) stating when a provider (facility or practitioner) bills the carrier, then the provider shall receive the maximum allowable payment in accord with these rules. Move a subrule to Rule 117.
• Rule 117: Adds carrier instructions regarding the Carrier’s Explanation of Benefits in sub (4).
• Rule 121: Language added strengthening payment of RN001 during the global surgery period.
• Rule 202: Adds language to sub (9) allowing the use of J coding when billing for drugs administered in the office setting.
• Rule 902: New rules in the billing section added for billing injectable medications in the office setting. If the provider omits, the National drug code, the carrier may reimburse the drug using the least costly NDC.
• Rule 904: Deletes modifier –PC.
• Rule 915: Adds language to cite the American Society for Anesthesiologist, Value guide in Rule 107 to determine the base for anesthesia units. Revises passive language in subrule (4) & (5). Deletes subrule 12.
• Rule 916: Corrected codes in Table 916. Procedure codes 90801-990815 should read: 90801-90815.
• Rule 922: Updated the CPT® cite per AMA request in sub rule 3 and in subrules (4) & ((7) added clarifying language for a hospital billing clinic services other than an industrial medicine clinic. Deletes rule 924 and incorporate information from 924 into rule 418.10922. Table 10924 changed to Table 10922..
• Rule 923: Clarify practitioner billing in the hospital setting.
• Rule 924: Deleted as information put into Rule 922.
• Rule 925: Updates the CPT® cite per AMA request in sub rule (1).
• Rule 1002: Updates language on the conversion factor to set $47.01 for 2003.
• Rule 1204: Deletes duplicative language in subrule(4) and changes to active language.
• Rule 1206: In subrule 3 corrects typo in line 5. The word “to” had the “o” omitted.
• Rule 1501-: Separated information into separate rules. Adds Rule 1502 for Miscellaneous Procedures. In this rule 01999-PA: Consistent with other payers who do not pay this procedure. Delete codes 90471 and 90472 from miscellaneous table as RVU’s have been established and the MAP will be published in the manual at $5.64.
• Adds Rule 1503 for the lab codes with established fees set and adds Rule 1504 for the Orthotic and Prosthetic, L-code procedures.