Chapter 21: Other Services


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



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Effective July 1, 2013

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Look for possible updates and corrections to these payment policies

 

Table of contents

Payment policies:
After hours services
Locum tenens
Provider mileage
Ventilator management services

More info:
Related topics

Payment policy: After hours services

Services that can be billed

CPT® codes 99050 through 99060 will be considered for separate payment in the following circumstances:

  • When the provider’s office isn’t regularly open during the time the service is provided, or
  • When services are provided on an emergency basis, out of the office, that disrupt other scheduled office visits.

Note: Also see “Payment limits,” below.

Documentation requirements

Medical necessity and urgency of the service must be documented in the medical records and be available upon request.

Payment limits

Only one code for after hours services will be paid per worker per day.

A second day can’t be billed for a single episode of care that carries over from one calendar day to the next.

CPT® codes 99050 through 99060 aren’t payable when billed by:

  • Emergency room physicians,
  • Anesthesiologists/anesthetics,
  • Radiologists, or
  • Laboratory clinical staff.

Payment policy: Locum tenens

Who must perform these services to qualify for payment

A locum tenens physician must provide these services.

Link: For information about requirements for “Who may treat,” see WAC 296-20-015 .

Requirements for billing

The department requires all providers to obtain a provider account number to be eligible to treat workers and crime victims and receive payment for services rendered.

When billing for locum tenens services, the locum tenens physician must use HCPCS billing code modifier –Q6 (which is defined as, “Services furnished by a locum tenens physician”).

Note: Modifier –Q6 isn't covered and the insurer won't pay for services billed under another provider's account number.


Payment policy: Provider mileage

Prior authorization

Prior authorization is required for a provider to bill for mileage.

The round trip mileage must exceed 14 miles.

Note: Reimbursement for such provider mileage is limited to extremely rare circumstances.

Requirements for billing

To bill for preauthorized mileage:

  • Round trip mileage must exceed 14 miles, and
  • Use local billing code 1046M (Mileage, per mile, allowed when round trip exceeds 14 miles), which has a maximum fee of $4.94 per mile.

Note: (Also see “Prior authorization,” above.)
 


Payment policy: Ventilator management services

Services that can be billed

The insurer pays for either the:

  • Ventilation management service code (CPT® codes 94002-94005, 94660, and 94662), or
  • E/M service (CPT® codes 99201-99499),
  • But won’t pay both (also see “Payment limits,” below).

Payment limits

The insurer doesn’t pay for ventilator management services when the same provider reports an E/M service on the same day. If a provider bills a ventilator management code and an E/M service for the same day, payment:

  • Will be made for the E/M service, and
  • Won’t be made for the ventilator management code.

If you’re looking for more information about… Then go here:
Administrative rules for “Who may treat” Washington Administrative Code (WAC) 296-20-015:
http://apps.leg.wa.gov/wac/default.aspx?cite=296-20-015
Becoming an L&I provider L&I’s website:
www.Lni.wa.gov/ClaimsIns/Providers/Becoming/
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 © 2012 American Medical Association

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