WCC Practitioner Fee Schedule Revisions Memorandum - October 21, 1998

MEMORANDUM NO. 98-15

The purpose of this memorandum is to correct errors in the Official Connecticut Practitioner Fee Schedule and to provide answers to some questions that have been referred to this office.

1. On page 5 of the Fee Schedule the interest calculation example is incorrect. To find the interest factor appropriate for a late payment, the formula is the number of days from receipt of the complete bill filing (68) divided by 365 and multiplied by 10% (.10). The correct factor for interest is 68/365 x .10 = .0186. The total payment due the provider would be 1.0186 times the fee amount.

2. On page 6 of the Fee Schedule, item Q, the words "for the same injury" should be deleted.

3. On page 7 of the Fee Schedule, item G, the second paragraph should be changed to read, "This information is required for the initial visit for any new injury to a new body part that occurs to an established patient as well as the initial visit of a new patient. Visits that meet these guidelines will be reimbursed at level 4 for new patients and at level 3 for a new injury to a new body part for an established patient."

4. On page 7 of the Fee Schedule, item G, the fourth paragraph should read, "Visits that meet these guidelines will be paid at the appropriate level 2 rate." Everything after this should be deleted.

5. On page 7 of the Fee Schedule, "Other Guidelines", item A, the next to the last sentence should read, "Reimbursement for supplies and equipment must not exceed 130% of the acquisition price."

6. On page 73 of the Fee Schedule, CPT code 29888 should allow for an assistant surgeon.

7. On page 213 of the Fee Schedule, after the sentence that reads, "Code Q0103 is allowed only once per each compensable event," add the following: "This code eliminates the need to use codes 97001 and 97003 for an initial visit. Reevaluation codes 97002 and 97004 are to be used at the end of a treatment plan in determining any future course of action. The fee for this service is included in the $90 daily cap and should be incorporated in the activity on the final day of the treatment plan."

8. Down coding of bills is still appropriate when the billing code is incorrect; however, all down coding has to be explained on the explanation of the payment. This comment must contain the rationale for the down coding.

9. The guidelines do not allow for an RN to be an assistant surgeon. They do allow for a PA to be an assistant surgeon in hospitals that do not provide interns or residents. The reimbursement for a non-MD provider is 70% of the 20% of the surgical fee that would be paid to a physician acting as an assistant surgeon.

10. In regard to Pharmacy Reimbursement, page 7 of the Fee Schedule:

a. The dispensing fee applies to all sites of purchase including pharmacy, physician office and hospital.
b. The dispensing fee applies to all drug prescriptions.
c. The billing should be separate for ingredients and dispensing fee.
d. The NDC code must be included on the bill.

11. The guidelines do not anticipate that a physical therapist will use the 25 modifier. Payment should not exceed $90 except where the initial Q0103 code is applicable or where the payer is requesting additional information.

12. A chiropractor can bill for an initial evaluation separately from any manipulation charges. As the treating physician, the chiropractor is allowed to bill for a reevaluation over and above billing for treatment. This charge is in addition to the $90 allowable charge for treatment. The reevaluation is allowable at the end of the treatment plan in order to determine patient status and future direction. A reevaluation is not allowed more than once every 6 weeks and is subject to the documentation requirements outlined in "General Guidelines," section II G.

To order a copy of the Official Connecticut Practitioner Fee Schedule, please contact Medicode, Inc. at 1-800-999-4600.