WCC CPT Codes/Practitioner Fee Schedule/Billing Guidelines Memorandum - April 11, 1995

Confusion has been created by some of the changes that have been made in the CPT codes for 1995. The principal confusion concerns physical medicine and how it will be billed and paid for during the year. After a series of meetings among providers, insurers and managed care people the following rules have been agreed upon.

1.   Effective May 1, 1995 all billing for 1995, including physical medicine, will be done using the newly implemented 1995 CPT codes. All billing will be submitted on a HCFA 1500.

2.   Reimbursement will be based on the existing CPT 94 fee schedule with the exception of physical medicine and a minor addition to anesthesia, which are outlined below. The fee schedule applies only to those situations where there is no written contract between the provider and the payer. Where a contract exists the terms of the contract determine the reimbursement. 

3.   Section VII. D. of the existing Billing Guidelines is deleted and replaced as follows:

Physical Medicine.    Physical medicine is defined as that rendered by medical doctors, registered physical therapists, registered occupational therapists, podiatrists and chiropractors using CPT codes 97010-97799, 95831-95834, 95851-95852 and 98925-98929. Physical medicine codes will be indicated for each modality and procedure. Due to the 15 minute time increments some codes may be used more than once in a single day. The provider should list the code once and indicate the number of times the service was provided in the unit column on the HCFA form. Payment for physical medicine services will be based on fees developed by MDR using CPT 95 codes with their corresponding values. The maximum payment amount will not exceed $90.00 per each day of service. Visits for physical therapy may not exceed one visit per day without prior written approval from the payer.

The initial physical therapy visit will be identified by code HCPC code Q0103. The maximum payment amount will not exceed $90.00. In addition to an appropriate history and physical examination, the initial evaluation will also address length and duration of treatment and will establish the treatment plan. Short term and long term goals will be outlined. This initial physical therapy evaluation is separate and distinct from the medical provider's service. Payment for this evaluation is in addition to any other charges generated by actual services provided on that day. This code Q0103 is allowed only once per each compensable event.

Work Hardening, work conditioning and multiple body areas of treatment must be discussed between the payer and the provider. All discussion regarding price, length and duration of treatment must be agreed upon in writing; verbal agreements will not be recognized. A faxed signoff will be accepted.

4.   TENS (Transcutaneous Electrical Nerve Stimulation) must be provided only under the attending or treating physician's prescription. Written authorization from the payer must be obtained before purchase or rental arrangements are made for the TENS. The payer has sole right of selection of vendors for rental or purchase of equipment, supplies, etc.

5.   The opening paragraph of Section VII. B. of the Billing Guidelines is amended as follows:

Durable Medical Equipment. Durable medical equipment may include purchase and rental. Physicians and therapists must obtain authorization from the payer before purchase or rental of supplies, equipment, orthotics and prosthetics costing over $50.00 per item. The payer has sole right of selection of vendors. Reimbursement for supplies and equipment must not exceed 30% above the acquisition price. The following limits apply:

6.   All chronic pain programs and back school programs shall require written authorization from the payer. All issues regarding length, duration and cost of treatment must be agreed upon in advance.

7.   Anesthesia Section V. N. sub-section i of the Billing Guidelines is amended by adding the following at the end:

Post operative pain management will be identified as ASA code 01999 for PCA initiation. This will be assigned a 4.0 value. Follow up daily PCA will use ASA code 01997 with a value of 2.0. This is in addition to surgical anesthesia services.