Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims

Return to Billing & Payment Policies

Return to Fee Schedule Lookup

Effective July 1, 2012

Complete Chapter for printing

Link to updates & corrections

Look for possible updates and corrections to these payment policies

 

Table of contents

Definitions

Payment policies:
Copies of medical records
Reports and forms
Review of job offers and job analyses

More info:
Related topics

 

Definitions

Bundled:

A bundled procedure code isn’t payable separately because its value is accounted for and included in the payment for other services.  Bundled codes are identified in the fee schedules.

Pharmacy and DME providers can bill HCPCS codes listed as bundled in the fee schedules.  This is because, for these provider types, there isn’t an office visit or a procedure into which supplies can be bundled.

Link: For the legal definition of “bundled,” see WAC 296-20-01002.

By report (BR):

A code listed in the fee schedule as “BR” doesn’t have an established fee because the service is too unusual, variable, or new.  When billing for the code, the provider must provide a report that defines or describes the services or procedures.  The insurer will determine an appropriate fee based on the report.

Link: For more information, see WAC 296-20-01002.

Job analysis (JA):

A job analysis (JA) is a detailed evaluation of a specific job or type of job.  A JA is used to help determine the types of jobs a worker could reasonably perform considering the worker’s skills, work experience, and physical limitations or to determine the worker’s ability to perform a specific job.  The job evaluated in the JA may or may not be offered to the worker and it may or may not be linked to a specific employer.

Pharmacy and DME providers can bill HCPCS codes listed as bundled in the fee schedules.  This is because, for these provider types, there isn’t an office visit or a procedure into which supplies can be bundled.

Job description:

A job description is an employer’s brief evaluation of a specific job or type of job that the employer intends to offer a worker.

Job offer:

A job offer is based on an employer’s desire to offer a specific job to a worker.  The job offer may be based on a job description or a job analysis.

Link: For more information about job offers, see RCW 51.32.090(4).

 

Payment policy: Copies of medical records

Who must perform these services to qualify for payment

Only providers who have provided healthcare or vocational services to the worker may bill HCPCS code S9982.

Services that can be billed

If the insurer requests records from a healthcare provider, the insurer will pay for the requested services.

Note: The insurer will pay for requested copies of medical records, regardless of whether the provider is currently treating the worker or has treated the worker at some time in the past, including prior to the injury.

Providers may bill for copies of medical records requested by the insurer using HCPCS code S9982 (maximum fee is $0.48 per page).

Payment will be made per copied page.

Payment limits

Payment for S9982 includes all costs, including postage.

S9982 isn’t payable for services required to support billing or to commercial copy centers or printers who reproduce records for providers.

Payment policy: Reports and forms

Services that can be billed

To bill for special reports or forms required by the insurer, providers should use the CPT® or local billing codes listed in the following table. The fees listed in the table below include postage for sending documents to the insurer.

Note: When required, the insurer will send special reports and forms.

If the report or form is…	Then bill using this CPT® or local billing code:	Which has a maximum fee of:	Also, be aware of these special notes about the report or form:
60 Day Report	99080	$43.86	60 day reports are required per WAC 296-20-06101 and don’t need to be requested by the insurer. Won’t pay for records required to support billing or for review of records included in other services. Limit of 1 per 60 days per claim.
Special Report (Requested by insurer or VRC)	99080	$43.86	Must be requested by insurer or vocational counselor. Won’t pay for records or reports required to support billing or for review of records included in other services. Don’t use this code for forms or reports with assigned codes. Limit of 1 per day.
Loss of Earning Power (LEP)	1027M	$19.08	Must be requested by insurer. Payable only to attending provider. Limit of 1 per day.
Report of Industrial Injury or Occupational Disease/ Report of Accident (ROA) – for State Fund claims	1040M	$38.14 $28.14 $18.14	MD, DO, DC, ND, DPM, DDS, ARNP, PA, and OD may sign and be paid for completion of this form. Paid when initiated by the worker or by a provider listed above. Limit of 1 per claim. When submitted within 5 business days after first treatment date When submitted 6-8 business days after first treatment date When submitted 9 or more business days after first treatment date
Physician’s Initial Report (PIR) – for Self Insured claims	1040M	$38.14 $28.14 $18.14	MD, DO, DC, ND, DPM, DDS, ARNP, PA, and OD may sign and be paid for completion of this form. Paid when initiated by the worker or by a provider listed above. Limit of 1 per claim. When submitted within 5 business days after first treatment date When submitted 6-8 business days after first treatment date When submitted 9 or more business days after first treatment date
Application to Reopen Claim	1041M	$49.57	MD, DO, DC, ND, DPM, DDS, ARNP, PA, and OD may sign and be paid for completion of this form. May be initiated by the worker or insurer (see WAC 296-20-097 ). Limit of 1 per request.
Occupational Disease History Form	1055M	$185.03	Must be requested by insurer. Payable only to attending provider. Includes review of worker information and preparation of report on relationship of occupational history to present condition(s).
Opioid Progress Report Supplement or any standardized objective tool to evaluate pain and function	1057M	$30.51	Payable only to attending provider. Paid when the worker is prescribed opioids for chronic, non-cancer pain. Must be submitted at least every 60 days (see WACs 296-20-03021 , -03022 and the L&I Medical Treatment Guidelines). Limit of 1 per day.
Attending Doctor Review of Independent Medical Exam (IME)	1063M	$38.14	Must be requested by insurer. Payable only to attending provider. Limit of 1 per request.
Initial report documenting need for opioid treatment	1064M	$57.22	Payable only to the attending provider. Paid when initiating opioid treatment for chronic, non-cancer pain. See WAC 296-20-03020 and the L&I Medical Treatment Guidelines for what to include in the report.
Attending Doctor IME Written Report	1065M	$28.60	Must be requested by insurer. Payable only to attending provider when submitting a separate report of IME review. Limit of 1 per request.
Provider Review of Video Materials with report	1066M	By report	Must be requested by insurer. Payable once per provider per day. Report must include actual time spent reviewing the video materials.  Won’t pay in addition to CPT® code 99080 or local codes 1104M or 1198M.
Insurer Activity Prescription Form (APF)	1073M	$49.57	Must be requested by insurer. Payable once per provider per worker per day.
AP response to VRC/Employer request about RTW	1074M	$30.51	For written communication with vocational counselors (VRC) and employers. Team conference, office visit, telephone call, or online communication with a VRC or employer can't be billed separately.

Note: See definition of by report in “Definitions” at the beginning of this chapter.

Link: More information on some of the reports and forms listed above is provided in WAC 296-20-06101.

Many L&I forms are available and can be downloaded from www.Lni.wa.gov/FormPublications/ and all reports and forms may be requested from the Provider Hotline at 1-800-848-0811.

 

Payment policy: Review of job offers and job analyses

(See definitions of job analysis (JA), job description, and job offer in “Definitions” at the beginning of this chapter.)

Prior authorization

Required

Prior authorization is required for review of JAs and job descriptions if not requested by the insurer, employer or vocational provider.

Who must perform these services to qualify for payment

Job offers

Attending providers must review the physical requirements documented in the job description or job analysis of any job offer submitted by the employer of record and determine whether the worker can perform that job.

Note: Whenever the employer asks, the attending provider should send the employer an estimate of physical capacities or physical restrictions and review each job description or job analysis submitted by the employer to determine whether the worker can perform that job.

JAs and job descriptions

Attending providers, independent medical examiners and consultants will be paid for review of job descriptions or JAs.

Note: A job description/JA review may be performed at the request of the employer, the insurer, vocational rehabilitation counselor (VRC), or TPA.  This service is payable in addition to other services performed on the same day.

Reviews requested by other persons (for example, attorneys or workers) won’t be paid.

 

Services that can be billed

If the report or form is…	Then bill using this CPT® or local billing code:	Which has a maximum fee of:	Also, be aware of these special notes about the report or form:
Review of Job Descriptions or JA	1038M	$49.57	Must be requested by insurer, employer or vocational provider. Payable to attending provider,  IME examiner or consultant. Limit of 1 per day. Isn’t payable to IME examiner on the same day as the IME is performed.
Review of Job Descriptions or JA, each additional review	1028M	$37.19	Must be requested by insurer, employer or vocational counselor. Payable to attending provider, IME examiner or consultant. Bill to L&I. For IME examiners on day of exam: may be billed for each additional JA after the first 2. For IME examiners after the day of exam: may be billed for each additional JA after the initial (initial is billed using 1038M).

Links: Related topics

If you’re looking for more information about…	Then go here:
Administrative rules for information in this chapter	Washington Administrative Code (WAC) 296-20-06101: http://apps.leg.wa.gov/wac/default.aspx?cite=296-20-06101 WAC 296-20-097: http://apps.leg.wa.gov/wac/default.aspx?cite=296-20-097 WAC 296-20-03020: http://apps.leg.wa.gov/wac/default.aspx?cite=296-20-03020 WAC 296-20-03021: http://apps.leg.wa.gov/wac/default.aspx?cite=296-20-0021 WAC 296-20-03022: http://apps.leg.wa.gov/wac/default.aspx?cite=296-20-03022
Becoming an L&I provider	L&I’s website: www.Lni.wa.gov/ClaimsIns/Providers/Becoming/default.asp
Billing instructions and forms	Chapter 2: Information for All Providers
Fee schedules for all healthcare services	L&I’s website: www.feeschedules.Lni.wa.gov
L&I forms	L&I’s website: www.Lni.wa.gov/FormPublications/

Need more help?  Call L&I’s Provider Hotline at 1-800-848-0811.

CPT® codes and descriptions only are © 2011 American Medical Association