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Professional Services -

General Information

COVERED SERVICES

L&I makes general policy decisions, called medical coverage decisions, to ensure quality of care and prompt treatment of workers. Medical coverage decisions include or exclude a specific health care service as a covered benefit.

Procedure codes listed as not covered in the fee schedules are not covered for the following reasons:

1. The treatment is not safe or effective; or is controversial, obsolete, investigational or
   experimental.
2. The procedure or service is generally not used to treat industrial injuries or occupational
   diseases.
3. The procedure or service is payable under another code.

The insurer may pay for procedures in the first 2 categories above on a case-by-case basis. The health care provider must:

• Submit a written request and
• Obtain approval from the insurer prior to performing any procedure in these categories.

The request must contain:

• The reason,
• The potential risks and expected benefits,
• The relationship to the accepted condition and
• Any additional information about the procedure that may be requested by the insurer.

For more information on coverage decisions and covered services, refer to WAC 296-20 sections -01505, -02700 through -02850, -030, -03001, -03002 and -1102.

UNITS OF SERVICE

Payment for billing codes that do not specify a time increment or unit of measure is limited to 1 unit per day. For example, only 1 unit is payable for CPT code 97022 regardless of how long the therapy lasts.

UNLISTED CODES

A covered service or procedure may be provided that does not have a specific code or payment level listed in the fee schedules. When reporting such a service, the appropriate unlisted procedure code may be used and a special report is required as supporting documentation. No additional payment is made for the supporting documentation. Refer to Chapter 296-20 WAC (including the definition section) and to the fee schedules for additional information.

PHYSICIAN ASSISTANTS

Physician assistants (PAs) must be certified and have valid individual L&I provider account numbers to be paid for services. PAs should use billing modifiers outlined in the RBRVS Payment Policies Section of MARFS. For example, to bill for Assistant at Surgery, the PA would use modifier –80, –81 or –82 as appropriate.

Physician assistants may sign any documentation required by the department. Consultations and impairment ratings services related to workers‘ compensation benefit determinations are not payable to physician assistants as specified in RCW 51.28.100 and WAC 296-20-01501.
Physician assistant services are paid to the supervising physician or employer at a maximum of 90% of the allowed fee. For more information about physician assistant services and payment, see WAC 296-20-12501 and WAC 296-20-01501.