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AK Work Comp Update August

Thursday, August 25, 2016   (0 Comments)
Posted by: Sheri Ryan
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Alaska Workers' Comp Giving YOU Fits?    

Having problems with Alaska Workers' Compensation paying less than the amounts on the fee schedule?  Not getting paid for some codes at all?  Here's an explanation of how things are being interpreted which may assist you and explain the situation.  If you have other issues, please let us know!  We are trying to get clarification and changes through the AK WC Medical Services Review Committee (MSRC).  The MSRC makes recommendations to the AK Work Comp Board.  

AK Workers' Compensation adopted CMS Billing and Coding Guidelines.  Most chiropractic offices are unfamiliar with the majority of CMS Billing and Coding Guidelines because CMS greatly limits which codes chiropractors can be reimbursed for.  CMS has a Multiple Procedure Payment Reduction (MPPR) applicable for selected "Always Therapy Services.  It applies to both physicians and non-physician practitioners.  Here's a link to the CMS MLN Matters article that details out how the MPPR works.

Page 2 of the article does a really good job of illustrating the math on how that reduction is applied.  The MPPR applies to the PE payment when more than one unit OR procedure is provided to the same patient on the same day.  The MPPR applies to multiple units as well as multiple procedures.  Full payment is made for the unit or procedure with the highest PE payment.  Full payment is made for work and malpractice and 50 percent payment is made for the PE for subsequent units and procedures, furnished to the same patient on the same day.   This MPPR applies to almost all the commonly used therapy codes by chiropractors including 97124 (massage therapy) and 97140 (manual therapy).  For therapy services furnished by a group practice, the MPPR applies to all services furnished to a patient on the same day, regardless of whether the services are provided by one health care practitioner or numerous health care practitioners.   

97014 Muscle Stim - Still using code 97014 for Electrical Muscle Stim (unattended)?  97014 is assigned status code "I" = Not valid for Medicare purposes.  Medicare uses another code for reporting of, and payment for these services.  Medicare uses G0283, Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care.  We are trying to get the "I" status code addressed at the WC MSRC but you should be able to bill G0283 so long as it is part of a therapy plan of care.  

 85% Rule for services provided by healthcare providers other than physicians - 8 AAC 45.083 (L) (l) For medical treatment or services provided by other providers, the maximum allowable reimbursement for medical services provided by providers other than physicians, hospitals, outpatient clinics, or ambulatory surgical centers, is the lowest of 85 percent of billed charges, the fee or charge for the treatment or service when provided to the general public, or the fee or charge for the treatment or service negotiated by the provider and the employer.

This AK Work Comp regulation applies to Advanced Nurse Practitioners, Physicians Assistants, as well as Licensed Massage Therapists.  Massage services performed by a Licensed Massage Therapist will NOT be paid at the full physician fee schedule rate.  

 Codes with no RVU assigned and non-physician provided services paid at 85% of Billed Charges - Regulation 8 AAC 45.083 (G) and (L) both currently read that charges will be paid at 85 percent of "billed" charges .  There are multiple definition issues that are being looked at by the WC MSRC.  We believe the regulation didn't get written correctly and it should have been 85 percent of the allowable fee schedule.  8 AAC 45.083 (g) The maximum allowable reimbursement for medical services that do not have current Centers for Medicare and Medicaid Services, Current Procedural Terminology, or Healthcare Common Procedure Coding System codes, a currently assigned Centers for Medicare and Medicaid Services relative value, or an established conversion factor is the lowest of 85 percent of billed charges, the charge for the treatment or service when provided to the general public, or the charge for the treatment or service negotiated by the provider and the employer.

There are also codes that have relative values but are given a status code of N = Non-covered Services.  These services are not covered by Medicare.  This is where extraspinal manipulation (98943) and acupuncture codes (97810, 97811, 97813, 97814) fall.  We are trying to get this addressed in the WC MSRC as well.  

The Alaska Chiropractic Society favors global NCCI edit carve outs for specific “N” and “I” status codes that would not otherwise be covered under the AK Workers' Compensation Fee schedule.  However, the ACS is against a "carve out" of specific codes for designated "chiropractic services".  ACS does not believe that adopting Medicare coverage policies was the legislative intent of HB 316.  The only acceptable scenario regarding the new AK Workers' Compensation Fee Schedule regulations adopting "CMS billing and coding rules" in reference to chiropractic services is that Doctors of Chiropractic be allowed to practice in Alaska within their scope of practice with no limit of coverage at the physician level status, as allowed under state statute.  ACS recommends that clarifying language be inserted into 8 AAC 45.083 such as "Notwithstanding Medicare payment policies, Chiropractors may be reimbursed for services within their scope of practice act."   

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