69L-7: WORKERS' COMPENSATION MEDICAL REIMBURSEMENT AND UTILIZATION REVIEW
69L-7.020: Florida Workers' Compensation Health Care Provider Reimbursement Manual
69L-7.100: Florida Workers' Compensation Reimbursement Manual for Ambulatory Surgical Centers (ASCs)
69L-7.501: Florida Workers' Compensation Reimbursement Manual for Hospitals
PURPOSE AND EFFECT: To adopt the new versions of the Florida Workers' Compensation Health Care Provider Reimbursement Manual, the Florida Workers' Compensation Reimbursement Manual for Ambulatory Surgical Centers, and the Florida Workers' Compensation Reimbursement Manual for Hospitals, 2006 Editions, to implement the reimbursement rates authorized by the Three Member Panel pursuant to Section 440.13(12) F.S., at its meeting on April 11, 2006. In addition, the proposed rules 69L-7.020 and 69L-7.100 will adopt updated versions of the Physicians’ Current Procedural Terminology Manual and the American Medical Association “Healthcare Common Procedure Coding System, Medicare’s National Level II Codes Manual.
SUBJECT AREA TO BE ADDRESSED: Proposed revisions to workers’ compensation reimbursement manuals incorporated by reference into the rules, including amendments to the uniform schedules of maximum reimbursement allowances.
SPECIFIC AUTHORITY: 440.13(14) FS. 440.591
LAW IMPLEMENTED: 440.13(7) FS. 440.13(12) FS. 440.13(14) FS.
A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:
TIME AND DATE: May 16, 2006, 10:00 a.m.
PLACE: Room 104J, Hartman Building, 2012 Capital Circle Southeast, Tallahassee, Florida.
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Don Davis, Division of Workers’ Compensation, Office of Data Quality and Collection, Department of Financial Services, 200 East Gaines Street, Tallahassee, Florida, 32399-4226, telephone 850-413-1711.
THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:
69L-7.020
(1) The Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 20062005 Second Edition, is adopted by reference as part of this rule. The manual contains the Maximum Reimbursement Allowances determined by the Three-Member Panel, pursuant to section 440.13 (12), Florida Statutes and establishes reimbursement policies, guidelines, codes and maximum reimbursement allowances for services and supplies provided by health care providers. Also, the manual includes reimbursement policies and payment methodologies for pharmacists and medical suppliers.
(2) The Physicians’ Current Procedural Terminology (CPT®), 20062005 Professional Edition, Copyright 20052004, American Medical Association; the Current Dental Terminology, CDT-2005, Copyright 2004, American Dental Association; and in part for D codes and for injectable J codes, and for other medical services and supply codes, the American Medical Association “Healthcare Common Procedure Coding System, Medicare’s National Level II Codes, HCPCS 20062005”, EighteenthSeventeenth Edition, Copyright 20052004, Ingenix Publishing Group, are adopted by reference as part of this rule. When a health care provider performs a procedure or service which is not listed in the Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 20062005 Second Edition incorporated above, the provider must use a code contained in the CPT®-2006, CDT-2005 or HCPCS-2006 as specified in this section.
(3) The Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 20062005 Second Edition incorporated above, is available for inspection during normal business hours at the Florida Department of Financial Services, Document Processing Section,
Specific Authority 440.13(14)(b), 440.591 FS. Law Implemented 440.13(7), (12), (14) FS. History–New 10-1-82, Amended 3-16-83, 11-6-83,5-21-85, Formerly 38F-7.20, Amended 4-1-88, 7-20-88, 6-1-91, 4-29-92, 2-18-96, 9-1-97, 12-15-97, 9-17-98, 9-30-01, 7-7-02, Formerly 38F-7.020, 4L-7.020, Amended 12-4-03, 1-1-04, 7-4-04, 5-9-05, 9-4-05, Amended________.
69L-7.100
(1) The Florida Workers’ Compensation Reimbursement Manual for 2005 Edition, (ASC Reimbursement Manual) is incorporatedadopted by reference as part of this rule. The ASC Reimbursement Mmanual contains the Maximum Reimbursement Allowances determined by the Three-Member Panel, pursuant to section 440.13 (12), Florida Statutes and establishes reimbursement policies, guidelines, codes and maximum reimbursement allowances (MRA’s) for ambulatory surgical facility services, which are items and services provided to an injured worker in connection with a surgical procedure performed in an Ambulatory Surgical Center. The ASC Reimbursement Mmanual contains basic instructions and information for all ambulatory surgical centers and insurers concerning reimbursement of claims for ambulatory surgical facility services.is available for inspection during normal business hours at the Florida Department of Financial Services, Document Processing Section,
(2) The division has incorporated in the Florida Workers’ CompensationASC Reimbursement Manual for Ambulatory Surgical Centers, 2005 Edition,refers to a number of procedure codes and modifiers that are consistent with the Physicians’ Current Procedural Terminology (CPT®), 2005 Profession Edition, Copyright 2004, American Medical Association. Thisdeveloped and published by the American Medical Association. When a service or procedure is performed that does not have a code listed in the ASC Reimbursement Manual, the Ambulatory Surgical Center shall refer to the Physicians’ Current Procedural Terminology (CPT®), 2006 Professional Edition, Copyright 2005, American Medical Association, publicationwhich is hereby incorporated is adopted by reference as part of this rule. When a procedure is performed which is not listed in the manual, the ambulatory surgical center must use the appropriate code and deor contained in the Physicians’ Current Procedural Terminology (CPT®), 2005 Professional Edition, Copyright 2004, American Medical Association.
(3) The Florida Workers’ Compensation Reimbursement Manual for Ambulatory Surgical Centers, 2005 Edition, incorporated above, is available for inspection during normal business hours at the Florida Department of Financial Services, Document Processing Section,
(3) The Current Dental Terminology (CDT-2005), Copyright 2004, American Dental Association, and the Healthcare Common Procedure Coding System (HCPCS) 2006, Eighteenth Edition, Copyright 2005, Ingenix Publishing Group, are incorporated by reference as part of this rule, for dental D codes, injectable J codes, and other medical services or supply codes as specified in the ASC Reimbursement Manual.
(4) The
Specific Authority 440.13(4), (14), 440.591 FS. Law Implemented 440.13(7), (12), (14) FS. History–New 8-7-91, Amended 12-31-92, Formerly 38F-7.100, 4L-7.100, Amended 9-4-05, Amended ________.
69L-7.501
(1) Reimbursement Manual for Hospitals.
The Florida Workers’ Compensation Reimbursement Manual for Hospitals, 2006 2004, Second Edition, is adopted by reference as part of this rule. The Hospital Mmanual contains the Maximum Reimbursement Allowances determined by the Three-Member Panel, pursuant to section 440.13(12), Florida Statutes, and establishesreimbursement policyies, procedures, principles and standards for implementing statutory provisions regarding reimbursement for medically necessary services and supplies provided to injured workers in a hospital setting and per diem rates for hospital services and supplies.
The policies, procedures, principles and standards in the Manual are in addition to the requirements established by the
The Reimbursement Manual for Hospitals is available for inspection during normal business hours at the Florida Department of Financial Services, Document Processing Section, 200 East Gaines Street, Tallahassee, Florida 32399-0311, or may be obtained free of charge by print or download from the Department’s website at http://www.fldfs.com/wc.
(2) Billing Form for Hospitals.
Form DFS-F5-DWC-90, Uniform Bill (rev. 1992), also known as the UB-92, or HCFA-1450, is hereby incorporated by reference as part of this rule. The Form can be obtained free of charge by print or download from the web site for the Center for Medicare and Medicaid Services at http://www.cms.hhs.gov/forms/.
Instructions for completing Form DFS-F5-DWC-90 are available by reference to the UB-92, National Uniform Billing Data Element Specifications Manual, as adopted by the Florida State Uniform Billing Committee and specified in rule 69L-7.602, F.A.C. The UB-92 Manual and updates can be obtained from the
(3) Health Care Provider Reimbursement Manual.
The Florida Workers’ Compensation Health Care Provider Reimbursement Manual 20062004, Second Edition, which is incorporated by reference into rule 69L-7.020, F.A.C., is also incorporated by reference as part of this rule also. The billingcodes and maximum reimbursement allowances for physical therapy, occupational therapy, speech therapy, radiology and clinical laboratory services contained in the manualwhich shall be applied to hospital services provided on an outpatient basis onlywhen directed by the Reimbursement Manual for Hospitals incorporated by reference into this rule.
(3) The Florida Workers’ Compensation Health Care Provider Reimbursement Manual for Hospitals, incorporated in subsection (1) above, and Form DWC-90 areis available for inspection during normal business hours, at the State of Florida Department of Financial Services, Document Processing Section, 200 East Gaines Street, Tallahassee, Florida 32399-0311, or viamay be obtained free of charge by print or download from the Department’s website at http://www.fldfs.com/wc.
Specific Authority 440.13(14), 440.591 FS. Law Implemented 440.13(7), (12), (14) FS. History–New 6-9-87, Amended 6-1-92, 10-27-99, 7-3-01, Formerly 38F-7.501, 4L-7.501, Amended 12-4-03, 1-1-04, 7-4-04, Amended ________.