Chapter 33: Brain Injury Rehabilitation Services


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



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Effective July 1, 2012

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Payment policy:
Brain injury rehabilitation services


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Payment policy: Brain injury rehabilitation services

Note: The brain injury rehabilitation services policy is being revised.  Until the new policy is written, upon approval by an ONC or SIE/TPA individual services and therapies can be done separately through outpatient services when the provider submits a coordinated plan of care.  Services can include but aren’t limited to:

  • Psychotherapy services,
  • Speech therapy,
  • Medical services,
  • Neural therapy, and
  • Occupational therapy.

 

Prior authorization

Prior authorization is required for post acute brain injury rehabilitation evaluation and treatment.

State Fund claims

To determine whether or not to authorize post acute brain injury rehabilitation for a claim, both an ONC and L&I claim manager will review the claim separately.  (See “Approval criteria,” below.)

The Provider Hotline can’t authorize brain injury treatment; however, the Provider Hotline can advise if a prior authorization has been entered into the L&I claim system.

Self-insured claims

Contact the SIE/TPA for authorization (see “Approval criteria,” below).

Link: See SIE/TPA contact information at www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp.

Approval criteria

Before a worker can receive treatment, all of the following conditions must be met:

  • The insurer has allowed brain injury as an accepted condition under the claim, and
  • The brain injury is related to the industrial injury or is retarding recovery, and
  • The worker is physically, emotionally, cognitively and psychologically capable of full participation in the rehabilitation program, and
  • The screening evaluation done by the brain injury program demonstrates the worker is capable of new learning following the brain injury, and
  • The screening evaluation report by the program identifies specific goals to help the worker improve function or accommodate for lost function.

Who must perform these services to qualify for payment

Only providers approved by the department can provide post acute brain injury rehabilitation services for workers.

Qualifying programs

Post acute brain injury rehabilitation programs must include the following phases:

  • Evaluation,
  • Treatment, and
  • Follow up.

When a complete course of evaluation and treatment is required, L&I requires providers treating a patient on a State Fund claim to submit that plan to:

Department of Labor and Industries
Provider Accounts Unit
PO Box 44261
Olympia, WA 98504-4261

Special L&I provider account number required

Providers participating in the Brain Injury Program must have a special provider account number if they have CARF accreditation to treat and bill for a complete course of evaluation and treatment.

Providers may request a provider application or find out if they have a qualifying provider account number by calling the Provider Hotline at 1-800-848-0811.

Note: Providers billing for individual services and therapies don’t need to obtain a special provider account number.

Services that can be billed

Nonhospital based programs

The following local codes and payment amounts for nonhospital based outpatient post acute brain injury rehabilitation treatment programs are effective July 1, 2012:

Local code Description Maximum fee
8950H Comprehensive brain injury evaluation $4,331.91
8951H Post-acute brain injury rehabilitation full-day program, per day (minimum of 6 hours per day) $982.67
8952H Post-acute brain injury rehabilitation half-day program, per day (minimum 4 hours per day) $684.40

Hospital based programs

The following revenue codes and payment amounts for hospital-based outpatient post-acute brain injury rehabilitation treatment programs are effective July 1, 2012:

Local code Description Maximum fee
0014 Comprehensive brain injury evaluation $4,331.91
0015 Post-acute brain injury rehabilitation full-day program, per day (minimum of 6 hours per day) $982.67
0016 Post-acute brain injury rehabilitation half-day program, per day (minimum 4 hours per day) $684.40

Requirements for billing

For State Fund claims billing, providers participating in the Brain Injury Program must bill for brain rehabilitation services using the special post acute brain injury rehabilitation program provider account number assigned by L&I.  (See “Who must perform these services to qualify for payment,” above.)

Comprehensive brain Injury evaluation requirements

A comprehensive brain injury evaluation must be performed for all workers who are being considered for inpatient services or for an outpatient post acute brain injury rehabilitation treatment program. This evaluation is multidisciplinary and contains an in depth analysis of the worker’s mental, emotional, social, and physical status, and functioning.  The evaluation must be provided by a multidisciplinary team that includes all of the following:

  • Medical physician,
  • Psychologist,
  • Vocational rehabilitation specialist,
  • Physical therapist,
  • Occupational therapist,
  • Speech therapist, and
  • Neuropsychologist.

Additional medical consultations are referred through the program’s physician.  For State Fund claims, each consultation may be billed under the provider account number of the consulting physician.  Services must be preauthorized by an L&I claim manager or the self-insured employer.

Therapy assessments documentation requirements

The following documentation is required of providers when billing for post acute brain injury rehabilitation treatment programs:

  • Providers are required to keep a daily record of a workers attendance, activities, treatments and progress
  • All test results and scoring must also be kept in the workers medical record to include:
    • Documentation of interviews with family, and
    • Any coordination of care contacts (for example, phone calls and letters) made with providers or case managers not directly associated with the facility’s program.

Progress reports should be sent to the insurer regularly, including all preadmission and discharge reports.

Payment limits

Comprehensive Brain Injury Program Evaluation

The following tests and services are included in the price of performing a Comprehensive Brain Injury Program Evaluation and may not be billed separately:

  • Neuropsychological Diagnostic Interview(s), testing, and scoring,
  • Initial consultation and exam with the program’s physician,
  • Occupational and Physical Therapy evaluations,
  • Vocational Rehabilitation evaluation,
  • Speech and language evaluation, and
  • Comprehensive report.

Note: The above tests and service may be performed in any combination depending on the workers condition.

The complementary and/or preparatory work that may be necessary to complete the Comprehensive Brain Injury Evaluation is considered part of the provider’s administrative overhead.  It includes but isn’t limited to:

  • Obtaining and reviewing the workers historical medical records,
  • Interviewing family members, if applicable,
  • Phone contact and letters to other providers or community support services,
  • Writing the final report, and
  • Office supplies and materials required for service(s) delivery.

Treatment

These therapies, treatments, and/or services are included in the Brain Injury Program maximum fee schedule amount for the full day or half day brain injury rehabilitation treatment and may not be billed separately:

  • Physical therapy and occupational therapy,
  • Speech and language therapy,
  • Psychotherapy,
  • Behavioral modification and counseling,
  • Nursing and health education and pharmacology management,
  • Group therapy counseling,
  • Activities of daily living management,
  • Recreational therapy (including group outings),
  • Vocational counseling, and
  • Follow up interviews with the worker or family, which may include home visits and phone contacts.

Ancillary work, materials, and preparation that may be necessary to carry out Brain Injury Program functions and services are considered part of the provider’s administrative overhead and aren’t payable separately.  These include, but aren’t limited to:

  • Daily charting of patient progress and attendance
  • Report preparation
  • Case management services
  • Coordination of care
  • Team conferences and interdisciplinary staffing
  • Educational materials (for example, workbooks and tapes)

Follow up care is included in the cost of the full day or half day program. This includes, but isn’t limited to:

  • Telephone calls,
  • Home visits, and
  • Therapy assessments.

If you’re looking for more information about… Then go here:
Administrative rules for billing procedures Washington Administrative Code (WAC) 296-20-125:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-125
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 facility services L&I’s website:
http://feeschedules.Lni.wa.gov

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


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

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