CHAPTER 2 Final - Ohio Bureau of Workers' Compensation · PDF fileAugust 2017 2-1 Workers’ Compensation System Chapter 2 ... the Health Insurance Claim Form (CMS-1500), as the...

BWC’s Provider Billing and Reimbursement Manual

April 2018 2-1 Workers’ Compensation System

Chapter 2 - Services - Table of Contents I. GENERAL 2-3

A. Provider Number 2-3 B. Provider Services 2-3 C. Therapy Visits 2-3 D. Maximum Approval Period 2-4

II. PRACTITIONER SERVICES 2-4 A. Covered Medical Service Provider 2-4 B. Physician Assistant 2-4 C. Advanced Practice Nurse 2-5 D. Independent Social Worker 2-5 E. Professional Clinical Counselor 2-5 F. Social Worker 2-5 G. Professional Counselor 2-5 H. Physical Therapist, Occupational Therapist, Speech Pathologist and Massage

Therapist 2-5 I. Licensed Athletic Trainer 2-6 J. Non-Physician Acupuncturist 2-6 K. Urgent Care Facility 2-6 L. Ergonomist 2-6 M. Covered Vocational Rehabilitation Case Management Provider 2-7 N. Covered Vocational Rehabilitation Employment Specialist Provider

(OAC 4123-6-02.2(C)(17) ) 2-7 O. Non-Covered Provider 2-8 P. Guidelines (Provider Signature Grid) 2-8

III. HOSPITAL SERVICES 2-17 A. Eligible Providers 2-17 B. Definitions 2-18 C. Prior Authorization & Additional Information 2-18 D. Hospital Inpatient Reimbursement 2-18 E. Hospital Outpatient Reimbursement 2-20 F. Billing 2-20 G. Treatment Of Unrelated Illness Or Injury 2-20 H. Documentation Requirements 2-20 I. Prospective & Retrospective Hospital Bill Reviews 2-21 J. Covered & Non-Covered Revenue Codes 2-21 K. Revenue Codes Requiring CPT Codes for Hospital Outpatient Services 2-21 L. Valid Modifiers for Hospital Outpatient Services 2-21

IV. AMBULATORY SURGICAL CENTERS BILLING & REIMBURSEMENT 2-21 V. TRAUMATIC BRAIN INJURY 2-21

A. Definition 2-21 B. Purpose 2-21 C. Accreditation 2-22 D. Certification 2-22


August 2017 2-2 Workers’ Compensation System

E. Non-Hospital Based TBI Facilities 2-22 F. Types Of Brain Injury Rehabilitation Facilities 2-22 G. Authorization & Documentation Requirements 2-22 H. Non-Hospital Based Facilities Billing & Reimbursement Codes 2-23 I. Outpatient Brain Injury Rehabilitation/Day Treatment Programs 2-24

VI. OUTPATIENT MEDICATION PRIOR AUTHORIZATION PROGRAM 2-25 A. Rules Pertaining To Pharmacy Benefits 2-25 B. Pharmacy Benefits Manager 2-25 C. Prior Authorization 2-26 D. Generic & Brand Name Drugs 2-26 E. Injectable & Compounded Medication 2-26 F. Covered Services 2-27 G. Billing 2-27 H. Reimbursement Rates 2-28 I. Supply & Quantity Limits 2-28 J. Forms 2-29 K. Contacts 2-29

VII. HOME HEALTH AGENCY SERVICES 2-30 A. Eligible Providers 2-30 B. Services 2-30 C. Billing Requirements 2-32

VIII.NURSING HOME 2-32 IX. RESIDENTIAL CARE/ASSISTED LIVING FACILITY BILLING REQUIREMENTS 2-32 X. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) & NEURO-

MUSCULAR ELECTRICAL NERVE STIMULATION (NMES) 2-32 A. ORC 4752.02(A) 2-32 B. OAC 4123-6-43 2-32 C. DEFINITIONS FOR TENS & NMES 2-32 D. REQUIRED CRITERIA FOR TENS & NMES UNITS 2-33 E. OAC 4123-6-43 2-36 F. CODING & REIMBURSEMENT OF TENS/NMES 2-36

XI. LOW LEVEL LASER THERAPY 2-37 XII. OTHER BWC CERTIFIED PROVIDER SERVICES 2-37

A. Billing From All Other BWC Certified Providers 2-37 B. Medical Services Requests 2-37 C. Durable Medical Equipment 2-37 D. Equipment Used As Part Of A Surgical Procedure 2-38

XIII. SERVICES APPROVED AND REIMBURSED BY BWC RATHER THAN BY THE MCO 2-38 A. Caregiver Services 2-38 B. Home & Vehicle Modification 2-39 C. Non-Covered Services 2-41 D. Home Modifications 2-42 E. Vehicle Modifications 2-42 F. Prosthetics/Artificial Appliances 2-43 G. Interpreter Services 2-44 H. Catastrophic Case Management Plan (Previously Called Life Care Plan) 2-46



XIV.EXPOSURE OR CONTACT WITH BLOOD/POTENTIALLY INFECTIOUS MATERIALS WITH/WITHOUT PHYSICAL INJURY 2-47 A. Exposure Claim Processing 2-47 B. Exposure to Blood or Other Potentially Infectious Materials Policy & Procedure 2-48

XV. CHRONIC PAIN 2-48 A. Requirements 2-48 B. Chronic Pain Management Treatment Program Consideration 2-48 C. Injured Worker Eligibility 2-48 D. Inpatient Programs 2-49 E. Outpatient Programs 2-49 F. Services Provided By Chronic Pain Program 2-50 G. Services Billed Separately 2-50 H. Chronic Pain Program Per Diem Codes 2-50 I. Contractual Agreement 2-50 J. CMS-1500 2-50 K. Drug Testing Policy & Procedures 2-50

XVI.UTILIZING PRESCRIPTION MEDICATION FOR THE TREATMENT OF INTRACTABLE PAIN 2-51 A. Purpose 2-51 B. Issues Important To Ohio Workers’ Compensation 2-51 C. Statutes 2-51

XVII.SPINAL DECOMPRESSION THERAPY 2-55 A. Billing 2-55 B. Decision 2-55 C. Intent Of Decompression Therapy 2-55

XVIII.SMOKING DETERRENT PROGRAMS 2-55 A. Responsibility 2-55 B. Reimbursement Of Smoking Cessation Programs 2-55 C. Non-Covered Services 2-56 D. Provider Enrollment & Billing 2-56 E. Substance Abuse Treatment Services 2-56

I. GENERAL

A. Provider Number - A provider, who meets the qualifications to enroll as a Ohio Bureau of

Worker’s Compensation (BWC) provider, must enroll to receive an individual provider number. The provider must submit the individual provider number as the servicing provider number for billing purposes, unless otherwise noted below.

B. Provider Services - A provider that is eligible to provide services for an injured worker is

authorized by law to perform the service being billed and to practice within the scope of the provider’s license.

C. Therapy Visits – The maximum time allowable per visit for therapy services with timed

procedure codes (i.e., physical medicine, rehabilitation modalities and therapeutic procedures) should be no longer than one (1) hour without prior



authorization. If therapy services with timed codes are billed over one (1) hour per day, further medical review and approval shall occur if services were not authorized prior to the payment being made.

D. Maximum Approval Period – Timelines for delivery of medical treatments or services

with no specified timeframe on the request shall be no longer than thirty (30) days. Services not rendered in this time must have an update in the injured worker’s claim notes as to the rationale for the delayed service delivery. Services that run continuously over a longer timeframe (e.g., facility placement) shall not receive approval for more than six (6) months.

II. PRACTITIONER SERVICES - The following guidelines are intended to facilitate correct

coding and billing processes when used in conjunction with the American Medical Association “Physicians’ Current Procedural Terminology” (CPT®) book, American Medical Association’s monthly “CPT® Assistant” publication or the Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System (HCPCS) Level II dental codes.

A. Covered Medical Service Provider

1. Physician of Record a. The physician of record is the primary attending physician chosen by the injured

worker to direct treatment. The physician of record must be an eligible provider who is a BWC certified provider. The physician of record may or may not be a managed care organization (MCO) panel provider.

b. An injured worker with a date of injury prior to October 20, 1993, may retain a non-certified provider as a physician of record, if such relationship already exists.

c. Any request to change a physician of record must be changed to a BWC-certified provider. (Section II.P.b.)

2. An injured worker may have only one (1) physician of record at any given time, even in claims where more than one (1) physician treats the injured worker.

3. The MCO may not dispute an injured worker’s selection of a physician of record. 4. A physician of record must be a:

a. Medical Doctor; b. Doctor of Osteopathic Medicine; c. Doctor of Mechanotherapy; d. Doctor of Chiropractic; e. Doctor of Podiatry; f. Doctor of Dental Surgery; or g. Licensed Psychologist (e.g., PhD or PsyD).

B. Physician Assistant

1. The Physician Assistant provides services within the scope of the approved supervision agreement with the Physician Assistant collaborating or supervising physician(s).

2. BWC reimburses the Physician Assistant at eighty-five percent (85%) of the BWC Fee Schedule (https://www.bwc.ohio.gov/provider/services/FeeSchedules.asp). The reduction does not apply to supplies provided by the practitioner.

https://www.bwc.ohio.gov/provider/services/FeeSchedules.asp





3. The Physician Assistant may function as an assistant in surgery, in which case, reimbursement depends on both the assistant surgery modifier and the provider type. For example, if the fee for a procedure were $1,000.00, then that procedure billed with assistant surgery modifier -80 would pay twenty percent (20%) of $1,000.00 or $200.00. Since the Physician Assistant receives reimbursement at eighty-five percent (85%) of the BWC Fee Schedule, the fee in this case would be eighty-five percent (85%) of $200.00 or $170.00.

4. BWC cannot directly reimburse a Physician Assistant, but BWC can reimburse the supervising physician with whom the Physician Assistant has an approved supervision agreement. All services provided by a Physician Assistant shall be billed using the Physician Assistant’s BWC issued provider number typed into block 25 of the Health Insurance Claim Form (CMS-1500), as the Physician Assistant is the servicing provider. The BWC provider number issued to the supervising physician or physician group must be typed into block 33 of the CMS-1500 to reflect the pay-to-provider.

C. Advanced Practice Nurse 1. An Advanced Practice Nurse includes Certified Nurse Practitioners and Clinical

Nurse Specialists, acting within the scope of the standard care arrangement with their collaborating or supervising physician(s).

2. BWC reimburses the Advance Practice Nurse at eighty-five percent (85%) of the BWC Fee Schedule. The reduction does not apply to supplies provided by the practitioner.

3. An Advanced Practice Nurse enrolled with BWC may provide and be reimbursed for assistance in surgery services, in which case reimbursement is based on both the assistant surgery modifier and the provider type. For example, if the fee for a procedure were $1,000.00, then that procedure billed with assistant surgery modifier -80 would pay twenty percent (20%) of $1,000.00or $200.00. Since the Advanced Practice Nurse receives reimbursement at eighty-five percent (85%) of the BWC Fee Schedule, the fee in this case would be eighty-five percent (85%) of $200.00 or $170.00.

4. A Registered Nurse (CNOR) who is the first assistant in surgery, whom is not an Advanced Practice Nurse, may not enroll as a BWC provider and may not receive reimbursement for assistant surgery services.

D. Independent Social Worker – BWC reimburses an Independent Social Worker at eighty-

five percent (85%) of the BWC Fee Schedule. E. Professional Clinical Counselor - BWC reimburses a Professional Clinical Counselor at

eighty-five percent (85%) of the BWC Fee Schedule. F. Social Worker - BWC reimburses a Social Worker at seventy-five percent (75 %) of the

BWC Fee Schedule. G. Professional Counselor - BWC reimburses a Professional Counselor at seventy-five

(75%) of the BWC Fee Schedule. H. Physical Therapist, Occupational Therapist, Speech Pathologist and Massage Therapist











1. Physical Therapist, Occupational Therapist, Speech Pathologist and Massage Therapist must individually enroll with BWC if employed by mixed group practices (i.e., Medical Doctor, Doctor of Osteopathic Medicine, Doctor of Chiropractic, Advanced Practice Nurse, Physician Assistant, Physical Therapist, etc.).

2. Physical Therapist, Occupational Therapist, Speech Pathologist and Massage Therapist are not required to individually, enroll if employed by therapy groups, home health agencies, skilled nursing facilities or hospitals.

I. Licensed Athletic Trainer

1. A Licensed Athletic Trainer is eligible for enrollment by BWC. 2. Current Procedural Terminology (CPT®) codes 97005 and 97006, in addition to

other CPT® codes within the Licensed Athletic Trainer’s scope of practice, may be billed when providing the described services.

3. A Licensed Athletic Trainer must individually enroll with BWC if employed by mixed group practices (i.e., Medical Doctor, Doctor of Osteopathic Medicine, Doctor of Chiropractic, Advanced Practice Nurse, Physician Assistant, Physical Therapist, etc.).

4. It is not a requirement for a Licensed Athletic Trainer to individually enroll when employed by therapy groups, home health agencies, skilled nursing facilities or hospitals.

J. Non-Physician Acupuncturist 1. A Non-Physician Acupuncturist must have a state medical board certificate of

registration. 2. A Non-Physician Acupuncturist is a practitioner BWC reimburses for acupuncture

services only. 3. BWC does not reimburse evaluation and management codes to acupuncturists.

K. Urgent Care Facility

1. Free-Standing a. A freestanding urgent care facility must enroll as provider type 96. b. A freestanding urgent care facility may bill only for physician services. c. For reimbursement purposes, BWC shall treat freestanding urgent care centers

as any other physician clinic. d. BWC shall not reimburse freestanding urgent care centers a facility fee.

2. Hospital Based a. A hospital based urgent care facility must enroll as a hospital provider type and

be assigned a separate provider number. See Application for Provider Enrollment and Certification (MEDCO-13) form at BWC Website: https://www.bwc.ohio.gov/downloads/blankpdf/MEDCO-13.pdf.

b. A hospital based urgent care facility must be a part of the hospital cost report in order to receive reimbursement of a facility fee.

L. Ergonomist

1. To be BWC certified, an ergonomist must have one of the following certifications: a. Certified professional ergonomist; b. Certified human factors professional; c. Associate ergonomics professional; d. Associate human factors professional;

https://www.bwc.ohio.gov/downloads/blankpdf/MEDCO-13.pdf





e. Certified ergonomics associate; f. Certified safety professional with ergonomics specialist designation; g. Certified industrial ergonomist; h. Certified industrial hygienist; i. Assistive technology practitioner; or j. Rehabilitation engineering technologist.

2. Ergonomic services must be signed and dated by the actual servicing provider specifying the servicing provider’s credentials.

3. An employer signature is required on the action plan. 4. An Ergonomist may receive reimbursement for travel and mileage. See the BWC

Fee Schedule for current reimbursement rates.

M. Covered Vocational Rehabilitation Case Management Provider 1. To provide and receive payment for vocational rehabilitation case management,

including the services provided by an intern, the service provider must be BWC certified and enrolled.

2. Ohio Administrative Code (OAC) 4123-6-02.2(C)(48) identifies the type of credentials a vocational/medical case manager must maintain. A nationally recognized accreditation committee must have credentialed the provider in one of the following: a. Certified Rehabilitation Counselor; b. Certified Disability Management Specialist; c. Certified Rehabilitation Registered Nurse; d. Certified Vocational Evaluator; e. Certified Occupational Health Nurse; f. Certified Case Manager; or g. The American Board of Vocational Experts.

N. Covered Vocational Rehabilitation Employment Specialist Provider OAC 4123-6-

02.2(C)(17) 1. A covered vocational rehabilitation employment specialist provider provides job

placement, job development, job seeking skills training, job club and job coach services.

2. A covered vocational rehabilitation employment specialist provider must be BWC certified as a type 86 Employment Specialist to provide these services on or after 10/1/15.

3. The criteria for a covered vocational rehabilitation employment specialist provider to be BWC certified as a type 86 include: a. Attainment of certification in one of the following:

i. Certification for American Board of Vocational Experts; ii. Certified Rehabilitation Counselor; iii. Certified Case Manager; iv. Global Career Development Facilitator; v. Associate Certified Coach; vi. Professional Certified Coach; vii. Master Certified Coach; viii. Certified Disability Management Specialist; ix. Commission on Accreditation of Rehabilitation Facilities accreditation for

employment and community services in job development or employment supports; or

http://codes.ohio.gov/oac/4123-6-02.2

http://www.abve.net/





b. Evidence of the completion of three (3) or more courses, seminars or workshops prior to submitting an application for certification, totaling a minimum of eighty (80) hours and approved by BWC or by an entity offering a certification referenced above, in at least two (2) of the following domain areas: i. Job development; ii. Job placement; iii. Career and lifestyle development; iv. Vocational consultation and services for employers; v. Professional roles and practices; and/or vi. Ethic and utilization of community resources.

O. Non-Covered Provider

1. An individual provider is a provider who is not directly reimbursable by BWC and who cannot directly enroll with BWC. Examples of these providers include, but are not limited to: a. Physician Intern; b. Psychology Intern; c. Psychology Assistant; or d. An out-of-state provider, who provides services in a state that, does not have an

Ohio equivalent licensure requirement. e. The provider is permitted to give services under the direct supervision (i.e., in the

presence of the supervisor) of a provider who is licensed and enrolled by BWC to deliver such services. The licensed provider must bill for the services.

2. A network acting as a service coordinating entity only and not meeting qualifications for a provider type recognized by BWC that directly provides goods or medical services to the injured worker is a non-covered provider.

3. Direct manufacturer, supplier of surgical equipment or surgical supplies, is a non-covered provider.

P. Guidelines

1. Provider Signature on Medical Evidence - The following grid identifies provider types whose signature is acceptable on medical evidence.

PROVIDER TYPE Physician of Record (POR) or treating physician which includes the following: • Medical doctor

(M.D.), • Osteopath (D.O.), • Chiropractor

(D.C.), • Dentist (D.D.S.), • Mechanotherapist

(D.M.T.), • Podiatrist

(D.P.M.), • Psychologist, • Ophthalmologist.

Advanced Practice Nurse (A.P.N.) which includes the following: • Certified

Nurse Practitioner (C.N.P.),

• Certified Nurse Specialist (C.N.S.),

Physician Assistant (P.A.)

Licensed Independent Social Worker (L.I.S.W.)

Licensed Professional Clinical Counselor (L.P.C.C.)

Audiologist (A.U.D.) Optometrist (O.D.) Physical Therapist (P.T.) Occupational Therapist (O.T.)

Licensed Social Worker (L.S.W.)

Licensed Professional Counselor (L.P.C.) All other non-physician providers



FORM

Physician’s Report

of Work Ability (MEDCO-14)

YES *YES (see below) NO NO

NO

*For the first six weeks immediately following the date of injury, an A.P.N. and /or P.A. may independently complete and sign a MEDCO-14 to support payment or non-payment of temporary total disability. Subsequent MEDCO-14s must be co-signed by a physician who has examined the injured worker (IW) or has reviewed medical documentation of an A.P.N.’s and /or P.A.’s examination of the IW.

Request for Medical

Service Reimbursement or

Recommendation for Additional Conditions for Industrial Injury or

Occupational Disease

(C-9)

YES YES

YES

Medical Services Reimbursement

YES (see exception below)

NO

Recommendation for Additional Condition – NO

Exception: C-9s signed by a P.T. or O.T. for therapy services must be accompanied by a prescription from the POR or treating physician, an A.P.N. or P.A.

ADR Appeal to the MCO

Medical Treatment/Service

Decision (C-11) YES YES YES YES YES

Indicate causality designation and

provide signature on (in the “Treatment

info.” section of the) First Report of an

Injury, Occupational Disease or Death

(FROI-1)

YES YES YES NO NO

NOTE: FROI-1 applications may be filed by anyone, but the causality designation and provider signature in the “Treatment info.” section as noted can only to be completed by those providers designated above.

a. General Information Regarding Signatures on Medical Evidence:

i. An original or stamped signature on an application or medical evidence is acceptable.

ii. A form with a scanned signature is acceptable, but an electronic signature is not acceptable.

iii. Medical reports signed by a POR or treating physician’s authorized “scribe/designee” are acceptable. The scribe/designee will: a) Sign the POR or treating physician’s name. b) Enters his/her initials next to the POR or treating physician’s name.



b. Change of Physicians: i. To change a physician of record, the injured worker must submit written

notification to the MCO or self-insuring employer on the Notice to Change Physician of Record (C-23) or equivalent noting the following: a) Name and address of the new physician; b) Reason for the requested change; and c) Injured worker’s signature.

ii. The Notice to Change Physician of Record (C-23) form is on BWC Website: https://www.bwc.ohio.gov/bwccommon/forms/BWCForms/nlbwc/IWForms.asp.

2. Two (2) Physicians Treating At The Same Time (OAC 4123-6-27) - BWC shall not approve medical fees for treatment by more than one (1) physician for the same condition over the same period of time, except where a consultant, anesthesiologist, anesthetist or assistant surgeon is required or where the necessity for treatment by a specialist is clearly shown. The MCO, or in self-insuring employers’ claims, the self-insuring employer, shall approve an assistant surgeon in advance, except in cases of emergency.

3. Treatment Of Family Members (OAC 4123-6-06.2) - Except in cases of emergency, BWC shall not reimburse for treatment to an injured worker delivered, rendered or directly supervised by the injured worker or an immediate family member. Furthermore, the physician of record may not be the injured worker or an immediate family member. An immediate family member includes a: spouse, natural or adoptive parent, child or sibling, stepparent, stepchild, stepbrother, stepsister, father, mother, daughter, son, brother-in-law, sister-in-law, grandparent, spouse of a grandparent or grandchild.

4. Multiple Visits – The provider may bill only one (1) evaluation and management code, per provider/injured worker/date of service. If the injured worker has more than one (1) claim allowed, the claim involving the primary reason for the evaluation management service shall be billed. a. A provider may not bill for multiple claims when performing an evaluation and

management service. b. If the injured worker has more than one (1) claim allowed involving different parts

of the body, it may be appropriate to bill for services in more than one (1) claim. 5. Reimbursement For In-Home Physician Visits and Physician Mobile Office Visits

a. In-home physician visits, services shall require prior authorization after the first visit; however, the first and following visits must meet the three (3) prong test outlined in the “Miller Case Criteria” (click here) policy. The MCO shall approve appropriate in-home physician visits when the injured worker is homebound and unable to access outpatient facilities because of sensory impairment, immobility or transportation problems. An example of this scenario might include an injured worker with a catastrophic condition or an injured worker that requires end of life care. Lack of transportation does not constitute a medical reason for approving in-home physician visits.

b. The MCO shall grant prior approval according to the plan of care and health care needs of the injured worker. The MCO shall use the CPT® codes for home visits to reimburse the physician. The level of code must reflect current coding documentation standards for the CPT® level of service. Services rendered must only be those services indicated by medically necessary circumstances.

https://www.bwc.ohio.gov/downloads/blankpdf/C-23.pdf



https://www.bwc.ohio.gov/bwccommon/forms/BWCForms/nlbwc/IWForms.asp

https://www.bwc.ohio.gov/bwccommon/forms/BWCForms/nlbwc/IWForms.asp

https://www.bwc.ohio.gov/downloads/blankpdf/OAC4123-6-27.pdf

https://www.bwc.ohio.gov/downloads/blankpdf/OAC4123-6-06.2.pdf

https://www.bwc.ohio.gov/basics/PolicyLibrary/FileShell.aspx?file=%2fMedical+Policy%2fMiller+Case+Criteria.htm



c. BWC shall reimburse the mobile van or trailer physician visits or services, when the injured worker walks to the van or trailer, as part of a normal office visit according to CPT® levels of service and shall not be eligible for billing as a home visit. Mobile offices shall be billed using the appropriate office or other outpatient services CPT® evaluation and management code, with a place of service 15 (mobile unit) and shall be reimbursed at BWC’s Non-Facility Fee.

d. If a physician chooses to make a home visit to an injured worker who does not meet the criteria for a home visit or when determined by BWC and the MCO not to be medically necessary, the physician may not bill the services as a home visit. In these instances, the physician must use established home visit CPT® codes that are in effect on the date of the home visit.

6. Office Based Surgery - BWC follows state licensure requirements for enrollment of providers. The MCO and BWC staff who have knowledge of a physician or other licensed healthcare provider who may not be in compliance with the healthcare provider’s licensure requirements in regard to office based surgery or other issues, are encouraged to report this information to the State of Ohio Medical Board or other appropriate licensing Board. a. The physician who performs surgery in the physician’s office must follow the State of

Ohio Medical Board rules. BWC shall reimburse the following the State of Ohio Medical Board licensed providers that perform surgery in the licensed provider’s office: i. Medical Doctor; ii. Doctors of Osteopathic Medicine; and iii. Podiatrist.

b. BWC shall reimburse minor office-based procedures done by State of Ohio licensed Advanced Practice Nurses and Physician Assistants acting within the scope of their practice and under the supervision of a State of Ohio Medical Board licensed provider.

c. BWC shall reimburse providers of office surgery according to the BWC Fee Schedule at the Non-Facility Fee rate with an office place of service code.

7. Surgical Procedures Performed in the Emergency Department - BWC shall append modifier -54 to the CPT® code for all professional services billed for major and minor surgical procedures performed with the emergency department place of service (POS 23).

8. Unsupervised Physical Reconditioning Program (OAC 4123-6-07(B)(5)) – BWC and the MCO shall not approve reimbursement an unsupervised physical reconditioning program (e.g., services that are provided at a health club, YMCA, spa or nautilus facility) unless it is approved per the specific guidelines when an injured worker is participating in a vocational rehabilitation or remain at work program.

9. Billing Codes a. Professional reimbursement is in accordance with the OAC 4123-6-08. Refer to

the current BWC Fee Schedule for reimbursement rates http://www.bwc.ohio.gov/provider/services/agreement.asp.

b. BWC and the MCO shall accept: i. HCPCS Level I (CPT®) billing codes as established by the American Medical

Association. HCPCS Level I codes are descriptive codes for reporting medical services and procedures. Anesthesia CPT® codes (00100-01999) are recognized and required.

http://www.med.ohio.gov/








http://codes.ohio.gov/oac/4123-6-07v1

http://www.ohiobwc.com/basics/guidedtour/generalinfo/ORCandOAC.asp


http://www.ohiobwc.com/provider/services/agreement.asp



ii. HCPCS Level II billing codes as established by the Centers for Medicare and Medicaid Services. HCPCS Level II codes are descriptive codes for reporting durable medical equipment, dental, vision and other services.

iii. BWC local level billing codes are descriptive terms and identifying codes for services and equipment specific to Ohio workers’ compensation. Local codes begin with a “W” or “Z”.

10. Telephone Call Codes (99371-99373) - BWC is exempt from the Health Insurance Portability and Accountability Act and shall continue to recognize and reimburse the discontinued CPT® codes for telephone calls made by the appropriate provider. Please seek guidance in the Medical Documentation Policy. The telephone call codes are not reimbursable on the day of an office visit. During the visit, the time the practitioner spends on the phone with the injured worker present, contacting the employer, etc., must be documented and be included as part of the time component of the office visit. BWC shall not reimburse for new CPT® codes for evaluation and management services provided by telephone, as it is the position of BWC that an injured worker should have the injured worker’s care rendered in person.

11. Consultation Codes (CPT® codes 99241-99245 and 99251–99255) - Centers for Medicare and Medicaid Services no longer reimburse for inpatient and outpatient consultation visits. However, to continue to facilitate quality medical care, BWC shall continue to recognize and reimburse the current CPT® consultation codes as noted above. a. Consultative services differ from other evaluation and management codes in that

a physician provides the physician’s opinion regarding the evaluation and management of a specific problem. The physician provides advice after receiving a request to do so. Qualified non-physician practitioners may also provide consultations. Do not report ongoing management following the initial consultation service by the consultant with consultation service codes. Report these services as subsequent visits for the appropriate place of service and level of service.

b. Consultations require the following: i. The referring physician documents a request for an opinion on a specific

problem; ii. The consultant’s opinion is rendered and documented; and/or iii. Consultants report-back to the requesting physician.

12. Anesthesia Billing and Reimbursement Policy (Located in Section - New-Revised-Updated Policies of the PBRM)

13. By-Report codes for Professional Services (See Chapter 3) for Vocational Rehabilitation By-Report codes a. By-Report codes are codes for a procedure or service that are not typically

covered and BWC shall not routinely reimburse. No set fee is associated with the procedure or service. The provider should give information to the MCO to allow appropriate review.

b. Authorization and payment of By-Report codes require an individual analysis by the MCO prior to submission of the request for approval to BWC Medical Policy. MCO analysis includes: i. Researching the appropriateness of the By-Report code in relation to the

service or procedure; and ii. Appropriate cost comparisons.

http://www.ohiobwc.com/provider/services/meddocumentpolicy.asp



14. Bilateral Procedures (Modifier -50) a. The practitioner must identify bilateral surgical procedures that are performed at

the same operative session on one line, using the appropriate CPT® code and adding modifier -50 to identify the second (bilateral) procedure. This modifier pays one hundred fifty percent (150%) of the total allowed amount for the procedure performed.

b. The bilateral radiological procedures may be billed by using the appropriate CPT® code on one (1) line with two (2) units of service or left and right modifier on two (2) lines.

15. Reimbursement for Interpretation of Emergency Room X-rays a. The MCO shall reimburse the radiologist/specialist in situations where more than

one (1) physician such as the emergency room physician provides interpretation of the same emergency room x-ray for the same injured worker, for the same or different dates of service.

b. The MCO shall also reimburse the emergency room physician for the x-ray interpretation when the interpretation results in treatment of the injured worker. Examples include: i. Emergency room physician orders x-ray that results in diagnosis of fracture.

Emergency room physician applies cast. ii. Emergency room physician orders x-ray. No fracture is visible on x-ray.

Emergency room physician diagnoses strain/sprain and orders non-steroidal anti-inflammatory medication for pain.

c. If an emergency room physician orders an x-ray, does not treat the injured worker based on results of the x-ray and refers the injured worker to a physician specialist for the interpretation and treatment, BWC shall not reimburse the emergency room physician for the interpretation of the x-ray since it did not result in treatment by the emergency room physician.

16. Provider Reimbursement in Multiple Claims a. Evaluation and Management Services

i. General Rule a) A provider may receive reimbursement for only one (1) Evaluation and

Management service per injured worker per day. Exceptions shall be reviewed on a case-by-case basis.

b) Example: Evaluation and Management service was provided in the morning, but due to an unforeseen problem, the injured worker had to return later in the day for a reason that would require another complete Evaluation and Management service.

ii. Injured Worker with Multiple Claims - If a provider is treating an injured worker with multiple claims, the Evaluation and Management services may be billed in one (1) claim only for each visit. The service shall be billed to the claim representing the chief complaint or reason for the visit.

iii. Multiple Physicians - If multiple physicians of different specialties provide Evaluation and Management services to an injured worker on a single day for conditions allowed in a claim, upon review of documentation, the MCO may make a determination to reimburse each provider for the evaluation and management service, if appropriate.

b. Osteopathic Manipulative Treatment



i. Administrative Cost – BWC shall not provide additional reimbursement to cover administrative costs for billing in more than one (1) claim.

ii. Injured Worker with Two (2) Claims a) Reimbursement for osteopathic manipulative treatment provided in two

(2) claims shall be fifty percent (50%) of the BWC Fee Schedule for each claim.

b) Failure to use the modifiers in both claims shall cause BWC to deny the second bill submitted as a duplicate.

iii. Treatment of Body Regions in Injured Worker with Two (2) Claims a) If one (1) body region is allowed in each of the two (2) claims, each

claim may be billed with CPT® 98925. For the primary or most significant claim, modifier PC must be added to the code. Modifier SC must be added to the code in the second claim. If a total of three (3) or four (4) body regions are allowed and treated in two (2) claims, two-in-one claim and one-or-two in a second claim, each claim may be billed with 98926. For the primary or most significant claim, modifier PC must be added to the code. Modifier SC must be added to the code in the second claim

b) If a total of five (5) or six (6) body regions are allowed and treated in two (2) claims, each claim may be billed with 98927. For the primary or most significant claim, modifier PC must be added to the code. Modifier SC must be added to the code in the second claim.

iv. Injured Worker with More Than Two (2) Claims – BWC shall not routinely reimburse for osteopathic manipulative treatment in more than two (2) claims, and if rendered on the same date of service, BWC shall deny it.

c. Chiropractic Manipulative Treatment i. Administrative Cost – BWC shall not provide additional reimbursement to

cover administrative costs for billing in more than one (1) claim. ii. Injured Worker with Two Claims

a) Reimbursement for chiropractic manipulative treatment provided in two (2) claims shall be fifty percent (50%) of the BWC Fee Schedule for each claim.

b) Failure to use the modifiers in both claims shall cause BWC to deny the second bill submitted as a duplicate.

iii. Treatment of Spinal Regions in Injured Worker with Two (2) Claims a) If BWC allows one (1) spinal region in each of two (2) claims, each claim

may be billed with CPT® 98940. For the primary or most significant claim, modifier PC must be added to the code. Modifier SC must be added to the code in the second claim.

b) If a total of three (3) or four (4) spinal regions are allowed and treated in two (2) claims, two-in-one claim and one-or-two in a second claim, each claim may be billed with 98941. For the primary or most significant claim, modifier PC must be added to the code. Modifier SC must be added to the code in the second claim.

c) If a total of five (5) spinal regions are allowed and treated in two (2) claims, each claim may be billed with 98942. For the primary or most significant claim, modifier PC must be added to the code. The second claim must be billed with 98942 with modifier SC added to the code.





d) If BWC allows at least one (1) extra spinal region in each of two (2) claims, each claim may be billed with CPT® 98943. For the primary or most significant claim, modifier PC must be added to the code. Modifier SC must be added to the code in the second claim.

iv. Injured Worker with More than Two (2) Claims – BWC shall not routinely reimburse for chiropractic manipulative treatment in more than two (2) claims and if rendered on the same date of service, BWC shall deny it.

d. Physical Medicine Procedures i. Reimbursement for physical medicine procedures shall be at the BWC fee. ii. CPT® codes 97012 – 97028 are reimbursable in only one claim per date of

service as these codes describe treatments to one or more areas without time specifications

iii. CPT® codes 97032 – 97530: a) BWC may reimburse in only one (1) claim if a total of fifteen (15) minutes

or less are provided; and b) BWC may reimburse in more than one (1) claim if the total time units for

each service exceed one (1) unit or fifteen (15) minutes. i) For each fifteen (15) minutes, one (1) unit may be billed in each claim

using the modifier PT in the first claim and ST in the second claim. ii) An example of using CPT® code 97110 – Therapeutic exercises to

develop strength and endurance take place for thirty (30) minutes. If the injured worker has two (2) claims, one (1) unit can be billed in each.

17. Valid Modifiers a. Effective, January 1, 2015, BWC and the MCO accept all HCPCS and CPT®

modifiers on medical bills. The modifiers include ambulance modifiers to allow the provider to indicate the trip’s origin and destination.

b. BWC and the MCO shall continue to accept a small number of proprietary BWC modifiers in addition to the national standard modifiers.

a. Vocational Rehabilitation Modifiers (W2-W3) i. BWC recognizes three (3) levels of vocational rehabilitation case complexity.

Complexity Level 1 does not require a modifier and is reimbursed at one-hundred percent (100%) of the unit of service fee. Modifiers for Complexity Levels 2 and 3 and their corresponding levels of reimbursement are as follows: a) W2 Complexity Level 2 – One-hundred and three percent (103%) of unit

of service fee; and b) W3 Complexity Level 3 – One-hundred and four point two percent

(104.2%) of unit of service fee. ii. Additional information for the Vocational Rehabilitation Fee Schedule is

located at http://www.bwc.ohio.gov/provider/services/agreement.asp. Also, see the Vocational Rehabilitation Services in Chapter 3 of this manual.

b. Modifiers for Reimbursement for Multiple Claims i. BWC has four (4) proprietary modifiers used to allow reimbursement for

physical medicine treatment in two (2) claims for the same injured worker and date of service: a) PC-Primary Claim (osteopathic or chiropractic treatment) b) SC-Secondary Claim (osteopathic or chiropractic treatment) c) PT-Primary Claim (other physical medicine procedures) d) ST-Secondary Claim (other physical medicine procedures)

https://www.bwc.ohio.gov/downloads/blankpdf/VocRehabFeeSchedule2014.pdf

http://www.ohiobwc.com/provider/services/agreement.asp



ii. For additional information, refer to Section II.P.16. 18. Global Surgical Care for Professional Services

a. Continuity of care is an important component in the delivery of quality care. Thus, the physician performing surgery is in the best position to continue and/or arrange the coordination of all phases of care related to the surgical procedure. The global surgical package, also called global surgery or follow up days, includes all necessary services normally furnished by a surgeon or by members of the same group with the same specialty before, during and after a procedure.

b. BWC recognizes the industry standard ten (10) day global surgical period for minor surgical procedures. For major procedures, BWC established a sixty (60) day global surgical period instead of the industry standard of ninety (90) days. This is because the injured worker population often includes younger, healthier injured workers that can more quickly re-engage with the injured worker’s physician(s) of record after a major surgery, helping to facilitate a safe and timely return to work.

c. BWC recognizes that there are legitimate situations when all aspects of global surgical care are not rendered by the surgeon. For example, the pre-operative evaluation and/or the post-operative care may be performed by the injured worker’s family physician instead of the surgeon.

d. Correct coding guidelines require that when different physicians perform the components of a global surgical package, the same surgical procedure code (i.e., with the appropriate modifier) will be used by each physician to identify the services provided. This ensures that the provider receives the appropriate reimbursement for the services performed. The total or sum of reimbursement for all services performed in a global surgical care scenario is the same regardless of how the billing is divided between different providers involved in the injured worker’s care. Below are some examples of correct coding for these procedures: i. Surgeon Performs All Pre-Operative and Post-Operative Care - When the

surgeon performs the pre-operative, surgical and post-operative care, reimbursement is at one-hundred percent (100%) of the BWC Fee Schedule for the surgical procedure. No modifiers need to be reported.

ii. Repair of ruptured musculotendinous cuff (e.g. rotator cuff) open; acute must be reported with CPT® code 23410 with the date of service the care was rendered.

iii. Other Physician(s) Performs Pre-Operative and/or Post-Operative Care a) A physician providing only the pre-operative evaluation component of

a global surgical package (i.e., with another physician performing the surgical procedure and post-operative care) must report modifier 56 to the surgical procedure code. Reporting an evaluation and management visit code is inappropriate.

b) Repair of ruptured musculotendinous cuff (e.g. rotator cuff) open; acute must be reported as CPT® code 23410-56 with the date of service the care was rendered. BWC shall reimburse this portion of the procedure to the non-operating physician at ten percent (10%) of total fee of the rotator cuff repair.

c) A surgeon performing only the surgical component of a global surgical package (with another physician providing the post-operative care) must report modifier 54 with the surgical procedure code. Note: The physicians




involved in such care must first agree on the transfer of post-operative care.

d) Repair of ruptured musculotendinous cuff (e.g. rotator cuff) open; acute must be reported as CPT® code 23410-54 with the date of service the surgery was performed. BWC shall reimburse this portion of the procedure to the operating physician at seventy percent (70%) of total fee for the rotator cuff repair.

iv. A physician providing only the post-operative component of a global surgical package (i.e., with another physician performing the surgical procedure) must report modifier 55 with the surgical procedure code. Reporting an evaluation and management visit code is inappropriate. Note: The physicians involved in such care must first agree on the transfer of post-operative care. a) Repair of ruptured musculotendinous cuff (e.g. rotator cuff) open; acute

must be reported as CPT® code 23410-55 with the date of service the surgery was performed.

b) BWC shall reimburse this portion of the procedure to the non-operating physician at twenty percent (20%) of total fee of the rotator cuff repair.

v. When more than one (1) physician provides post-operative services included in the global package, the post-discharge care payments must be divided based on the number of days that each physician provides care. Please note that the physicians involved in such care must first agree on the0 transfer of post-operative care. Reporting of an evaluation and management visit code is inappropriate. a) Physician A provided twenty (20) days of post-operative care or one-

third (1/3) of the follow-up care for repair of ruptured musculotendinous cuff (e.g. rotator cuff), open acute must be reported as CPT® code 23410-55 with the date of service the surgery was performed and a note stating date span the care was provided reported on a hard copy CMS-1500. BWC shall reimburse this portion of the procedure to the provider at six point sixty-seven percent (6.67%) of total fee for the rotator cuff repair.

b) Physician B provided forty (40) days of post-operative care or two-thirds (2/3) of the follow-up care for repair of ruptured musculotendinous cuff (e.g. rotator cuff) open acute must be reported as CPT® code 23410-55 with the date of service the surgery was performed and a note stating date span the care was provided reported on a hard copy CMS-1500. BWC shall reimburse this portion of the procedure to the non-operating physician at thirteen point thirty-three percent (13.33%) of total fee for the rotator cuff repair.

III. HOSPITAL SERVICES

A. Eligible Providers - For the purposes of BWC, a hospital is an institution that provides

facilities for surgical and medical diagnosis and treatment of bed injured workers under the supervision of staff physicians and furnishes twenty-four (24) hour-a-day care by registered nurses. These facilities must have accreditation from the Joint Commission, Health Care Facilities Accreditation Program or the Commission on Accreditation of Rehabilitation Facilities for rehabilitation hospitals or approved by the Centers for Medicare and Medicaid Services or other organizations with approved deeming authority for Medicare participation.

https://www.jointcommission.org/accreditation/hospitals.aspx

http://www.hfap.org/

http://www.carf.org/home/

http://www.carf.org/home/



B. Definitions - BWC provides payment for medically necessary covered inpatient and outpatient services provided to injured workers for treatment of allowed compensable condition(s), subject to MCO or self-insured employer guidelines. 1. Inpatient (OAC 4123-6-01(K)(1); OAC 4123-6-37.1) — An injured worker admitted to

a hospital for bed occupancy for purposes of receiving inpatient hospital services. An injured worker is considered an inpatient if there is a formal order for admission from the physician. The determination of an inpatient stay is not based upon the number of hours involved. If it later develops during the uninterrupted stay that the injured worker is discharged, transferred to another inpatient unit within the hospital, transferred to another hospital, transferred to another state psychiatric facility or expires and does not actually use a bed overnight, the order from the attending physician addressing the type of encounter shall define the status of the stay.

2. Outpatient (OAC 4123-6-01(K)(2); OAC 4123-6-37.2) – The injured worker is not receiving inpatient care as defined above, but receives outpatient services at a hospital. An outpatient encounter cannot exceed seventy-two (72) hours of uninterrupted duration.

C. Prior Authorization & Additional Information 1. Inpatient Services - The MCO, or the self-insuring employer in self-insuring employer

claims, is responsible for authorizing and determining medical necessity for all non-emergency inpatient hospital services. The provider of record or treating physician is responsible for contacting the appropriate MCO or self-insuring employer for authorization guidelines. In cases of emergency, prior authorization is not required. The hospital must notify BWC, the MCO, Qualified Health Plans or the self-insuring employer within one (1) business day of emergency admission.

2. Outpatient Services - The MCO, or the self-insuring employer in self-insuring employer claims, is responsible for authorizing and determining medical necessity for all outpatient hospital services. The provider of record or treating physician is responsible for contacting the appropriate MCO or self-insuring employer for authorization guidelines. In cases of emergency, prior authorization is not required.

3. Emergency Department - Treatment in the emergency department of a hospital must be of an immediate nature to constitute an emergency (i.e., per OAC 4123-6-01 definition). Prior authorization of such treatment is not required; however, in situations where the emergency department is being utilized to deliver non-emergency care, notification shall be provided to the injured worker, hospital and provider of record that continued use of the emergency department for non-emergent services and shall not be reimbursed by BWC or the MCO.

D. Hospital Inpatient Reimbursement

1. Overview - BWC reimburses hospital inpatient services using a modified version of Medicare’s Inpatient Prospective Payment System. The modifications adopted by BWC are specified in OAC 4123-6-37.1. To view the current and previous hospital inpatient rules go to https://www.bwc.ohio.gov/basics/guidedtour/generalinfo/ORCandOAC.asp.

2. Interim Bills - BWC shall not process interim bills (i.e., bill types 112 and 113) for interim stays of less than thirty (30) days. For a length of stay of thirty (30) days or greater, the initial interim bill submitted shall be processed according to the applicable reimbursement methodology. Additional interim bills shall be reviewed manually and may result in an adjusted reimbursement amount.

http://www.ohiobwc.com/downloads/blankpdf/OAC4123-6-01.pdf

http://www.ohiobwc.com/downloads/blankpdf/OAC4123-6-37.1.pdf



https://www.bwc.ohio.gov/downloads/blankpdf/OAC4123-6-01.pdf


http://www.ohiobwc.com/

http://www.ohiobwc.com/



3. Late Charges - Hospital late charges cannot be submitted by hospitals to the MCO or BWC. Instead, the hospital must request adjustment of the initial bill. The hospital must include documentation of the hospital’s bill for late charges with the adjustment request. This documentation can be hard or soft copy (e.g., fax, email) of the Uniform Bill (UB-04) form or the electronic version of the UB-04 (i.e., EDI.NSF, etc). All submitted requests shall contain clearly identifiable data elements required for bill processing.

4. Provider Types Excluded From BWC’s Hospital Inpatient Reimbursement Methodology a. The following provider types are not reimbursed as hospitals by BWC:

i. Skilled nursing facility; ii. Skilled nursing facility units in a hospital; iii. Skilled nursing facility swing beds; iv. Residential care/assisted living facilities; or v. Adult day care.

d. BWC’s complete billing guidelines for these provider types are in Chapter 4 of this manual.

5. Appeals - All appeals regarding hospital inpatient reimbursement must be directed to the appropriate MCO. If the issue is not resolved to the hospital’s satisfaction, the hospital may submit a second level of appeal to BWC. Second level appeals must be directed to the BWC Provider Contact Center, Attn: Hospital Appeals at fax # 614-728-9534. When a hospital is appealing the amount of reimbursement for an inpatient hospitalization, it is the hospital’s responsibility to submit the supporting medical documentation for review.

6. Covered Services/Hospital Leave Of Absence - The MCO or self-insuring employer is responsible for authorizing a hospital leave of absence. BWC covers leave of absence from hospitals for catastrophic cases when the injured worker is admitted to learn new techniques and apply new strategies (i.e., involving daily activities) for the injured worker’s return home. The leave of absence from the hospital must be medically appropriate and express potential to be beneficial to the injured worker’s recuperation. BWC shall reimburse a reduced bed hold rate of fifty percent (50%) of the room and board rate. The leave of absence, when prior authorized, shall be billed using revenue center code 183.

7. Non-Covered Hospital Services OAC 4123-6-37 - Although the MCO or self-insuring employer is responsible for authorizing and determining medical necessity for all hospital services, in most cases, BWC shall not provide reimbursement for the following items: a. Convenience Items - Television, telephone, cosmetics, toiletries or other

convenience items and goods and services requested by the injured worker solely for convenience are not reimbursable. The injured worker should be billed directly for these services.

b. Private Rooms i. BWC shall reimburse hospitals at the semi-private room rate. Private rooms

are not covered unless the physician justifies that it is medically necessary. Reimbursement may be considered in the following instances: a) The injured worker's condition is such that recovery is jeopardized. b) The injured worker's condition may adversely affect other injured workers.

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS1196256.html





ii. An injured worker who requests a private room because of convenience may be billed the difference between private and semi-private rates. The injured worker who is provided a private room because of the unavailability of semi-private rooms shall not to be billed the difference.

E. Hospital Outpatient Reimbursement - BWC reimburses hospital outpatient services

using a modified version of Medicare’s Outpatient Prospective Payment System. The modifications adopted by BWC are specified in OAC 4123-6-37.2.

F. Billing 1. To facilitate accurate calculation of reimbursement in the outpatient prospective

payment methodology, hospitals should submit all outpatient charges for one (1) date of service or encounter on the same bill. a. In most cases, if charges from one (1) date of service or encounter are submitted

on separate bills, the first bill shall pay and subsequent bills shall be denied as potential duplicates.

b. Exception - Bills containing only therapy charges (e.g. physical, occupational or speech) shall not be denied as duplicates if any previously paid bills for the same date of service or date of service range do not contain therapy charges.

c. Additional charges may be added to a bill that has been paid or is in process. The hospital and MCO should work together to have the original bill adjusted.

d. Cycle bills are accepted; however, BWC shall not accept split cycle bills or overlapping dates of service.

2. All hospital services, billed hardcopy, must be submitted on the UB-04 using revenue center codes. For outpatient hospital services, a number of revenue codes require a corresponding CPT® code. Revenue codes requiring a corresponding CPT® code are noted in this chapter. For outpatient services, a date of service is required on each line of the UB-04 for each service rendered. Lines submitted on outpatient bills with a charge of $0.00 are accepted and shall be priced according to the hospital outpatient prospective payment methodology. Professional services may not be billed on the UB-04.

3. A hospitals providing these services must obtain a separate BWC provider number for billing purposes and follow specific billing guidelines for each provider type as set forth in “BWC’s Provider Billing and Reimbursement Manual.” For additional enrollment applications, or if you have questions regarding enrollment with BWC, contact Provider Relations at 1-800-644-6292.

G. Treatment Of Unrelated Illness Or Injury - Treatment for unrelated illness or injury, while the injured worker is hospitalized or receiving hospital outpatient services, including Emergency Department services, is not usually reimbursable by BWC. When such unrelated treatment is requested, the requesting physician must identify which services are necessary due to the industrial illness or injury and which are necessary due to the unrelated condition(s). The hospital may be required to remove unrelated charges from the bill.

H. Documentation Requirements – A hospital must submit documentation to support the

diagnosis and procedure codes reported on inpatient and outpatient bills. The MCO is required to validate codes reported by the hospital because coding impacts the reimbursement rates. 1. Documentation for inpatient services may include:







a. Admission history and physical; b. Emergency department report if applicable; c. Operative report if applicable; d. Discharge summary and/or progress notes if admission was forty-eight (48)

hours or longer in duration; e. Discharge note if admission was less than forty-eight (48) hours in duration; f. Consultations; and/or g. Additional documentation may be requested, including but not limited to temized

billing statements, laboratory, radiology and other diagnostic reports. 2. Documentation for outpatient services may include:

a. Clinical summary/notes; b. Radiology, laboratory, and other diagnostic study reports; c. Emergency department reports, if applicable; and/or d. Operative reports, if applicable.

I Prospective & Retrospective Hospital Bill Reviews - Prospective and retrospective

reviews shall be conducted on hospital bills. Reviews shall include but shall not be limited to the following: 1. Ensure services are medically necessary for treatment of the allowed claim

conditions; 2. Ensure services are related to allowed claim conditions; 3. Ensure correct coding; 4. Identification of billing errors; 5. Identification of reimbursement errors; and 6. Overpayments may be recovered according to the medical overpayment recovery

policy.

J. Covered & Non-Covered Revenue Codes (Removed. Now published in OAC 4123-6-37.1, Payment for Inpatient Hospital Services and OAC 4123-6-37.2, Payment for Outpatient Hospital Services).

K. Revenue Codes Requiring CPT Codes for Hospital Outpatient Services (Removed. Now published in OAC 4123-6-37.2).

L. Valid Modifiers for Hospital Outpatient Services - BWC recognizes all CPT and HCPCS

modifiers for hospital outpatient services in effect on the billed date of service. Per OAC 4123-6-37.2, reimbursement impacts are determined.

IV. AMBULATORY SURGICAL CENTER BILLING AND REIMBURSEMENT POLICY

(LOCATED IN SECTION - NEW-REVISED-UPDATED POLICIES OF THE PBRM) V. TRAUMATIC BRAIN INJURY (TBI)

A. Definition - TBI is an injury to the head arising from a blunt or penetrating trauma or from acceleration or deceleration forces.

B. Purpose - The TBI section of this manual covers “non-hospital based” brain injury

rehabilitation billing codes and services. For hospital-based brain injury services please see the inpatient and outpatient hospital sections of this manual.









C. Accreditation - BWC requires all non-hospital based brain injury facilities to be accredited by the Commission on Accreditation of Rehabilitation Facilities for brain injury services.

D. Certification - Brain injury rehabilitation facilities must be BWC certified; however, the MCO may approve treatment at a facility that is enrolled but not certified if the MCO determines no BWC certified facility is available.

E. Non-Hospital Based TBI Facilities - Non-hospital based brain injury rehabilitation

facilities should be BWC certified and enrolled as a type 82 provider (i.e., reference the BWC Provider Enrollment form, type 82 provider).

F. Types Of Brain Injury Rehabilitation Facilities:

1. A post-acute, brain injury rehabilitation facility is a facility that provides residential and/or outpatient post-acute rehabilitative care serving an injured worker who no longer require acute comprehensive inpatient care and is physically capable of participating in a brain injury rehabilitation program. Services provided in a post-acute brain injury facility are directed toward the development of the most optimal level of independent functioning. This level of care is not expected to have longer than 12-18 month duration. A neurobehavioral, brain injury facility is a post acute rehabilitation facility (as defined above) that additionally provides post-acute neurobehavioral rehabilitation for the individual with a brain injury who is exhibiting maladaptive behavior and changes in personality.

2. A transitional living placement facility is a facility that provides short-term reintegration services for the injured worker to transition into the community. These facilities may provide occupational therapy, physical therapy, speech therapy, job coaching, job development and job placement as appropriate for the injured worker.

3. A lifelong living TBI facility is a facility that provides long-term residential living services for an injured worker who is not able to return independently to the workforce and/or community.

G. Authorization & Documentation Requirements - The following requirements are applicable to non-hospital based post-acute brain injury rehabilitation facilities: 1. It is a requirement that all brain injury, rehabilitation services receive preauthorization

from the MCO. Approval for non-hospital based rehabilitation requires that a screening evaluation be performed that includes an analysis of the injured worker’s mental, emotional, social and physical status and function. The report should substantiate the injured worker needs for the particular facility and the services being requested. The work that may be necessary to complete the screening evaluation is considered part of the facility’s administrative overhead for appropriateness of acceptance of the injured worked to the injured worker’s facility.

2. Documentation must be submitted at least monthly or per the frequency required by the MCO for injured worker in post-acute, neurobehavioral or transitional living brain injury rehabilitation facilities. Medical documentation shall include, but is not limited to, the following: a. Initial treatment plan and/or status of treatment goals; b. Treatment history and expected discharge outcomes, to include projected

discharge date and the anticipated discharge placement;



c. Treatment team members and the number of hours the injured worker spends with the treatment team members;

d. Treatment progress summary and comparison/progress from previous reports; e. Test results and cognitive function assessment/scale (e.g., Ranchos Los Amigos

or Glasgow Coma scale), medical problems and how these relate to treatment; and

f. Family interaction, as appropriate. 3. Documentation must be submitted for lifelong living TBI residential services bi-

annually or sooner if requested by the MCO. H. Non-Hospital Based Facilities Billing & Reimbursement Codes - The “non-hospital

based” facilities use local billing codes. To find the current BWC reimbursement rates, please refer to the BWC Fee Schedule. The billing codes and service descriptions are as follows: 1. TBI local level BWC codes:

a. W0177 is billed for the reimbursement of post-acute brain injury residential rehabilitation services, all-inclusive daily rate.

b. W0178 is billed for the reimbursement of neurobehavioral residential brain injury rehabilitation services, all-inclusive daily rate.

c. W0179 is billed for the reimbursement of post-acute outpatient brain injury rehabilitation services (full day/6 hour minimum), all-inclusive daily rate.

b. W0181 is billed for the reimbursement of post-acute outpatient brain injury rehabilitation services (half day/3 hour minimum), all-inclusive daily rate.

c. W0182 is billed for the reimbursement of lifelong living brain injury residential rehabilitation services, all-inclusive daily rate.

d. W0183 is billed for TBI in house pharmacy services. e. W0184 is billed for TBI therapeutic leave of absence, twenty-five percent (25%)

of daily rate. f. W0185 is billed for the reimbursement of transitional living services.

2. Post acute brain injury rehabilitation, neurobehavioral, and transitional living services are billed as an all-inclusive code that shall include the following as determined necessary: a. Room and board; b. Restorative services such as physical therapy, occupational therapy, and speech

therapy; c. Psychotherapy; d. Group therapy; e. Recreational therapy (including group outings); f. Behavioral counseling; g. Vocational counseling; h. Nursing and case management services; i. Team conferences; j. Report preparation; k. Pharmacology management; l. Medical management; m. Appropriate level of direct and indirect supervision (including one-on-one sitter

services in a neurobehavioral brain injury facility); n. Nutritional and dietary monitoring; o. Structured schedule for activities of daily living; and p. Family involvement, which may include home visits and phone contacts.




3. The daily per diem rate for residential post-acute TBI rehabilitation services does not cover: a. Physician fees; b. Prescription medications; c. Durable medical equipment; and d. Medical services (i.e., labs or radiology or driver’s evaluations).

4. One-on-one sitter services may be provided as a separate service in a non-neurobehavioral environment, but must be pre-authorized. If one-on-one sitter services are required, the MCO shall evaluate and determine the appropriate service facility.

5. Lifelong living TBI residential programs are billed as an all-inclusive code that should include the following: a. Room and board; b. Nursing and staff oversight; c. Case management; team conferences and report preparation; d. Recreational activities, including group activities; e. Group therapy; f. Pharmacology management; g. Nutritional and dietary monitoring; h. Assistance with activities of daily living; and i. Family involvement, which may include, home visits and phone contracts.

6. The daily per diem rate for lifelong living TBI residential programs does not include: a. Physician fees; b. Individual physical and occupational therapy; c. Individual speech therapy and behavioral therapy; d. Prescription medications; e. Durable medical equipment; and f. Medical services (e.g., lab or radiology).

7. Lifelong living residential services, other than the TBI facilities, are billed using the appropriate residential fee code. This includes residential care/assisted living facilities and skilled nursing facilities.

I. Outpatient Brain Injury Rehabilitation/Day Treatment Programs

1. Post acute facilities (i.e., type 82 providers) that provide outpatient, day treatment programs shall use local billing codes to bill for service.

2. Full day, outpatient program reimbursement must be a minimum of six (6) hours and half-day programs must be a minimum of three (3) hours of integrated services as described below.

3. Day programs are billed as an all inclusive daily rate that includes any of the following: a. Medical director/physiatry; b. Physical therapy and occupational therapy; c. Speech and language therapy; d. Psychotherapy; e. Neuropsychiatry; f. Neuropsychology; g. Behavioral analysis, behavior modification and counseling; h. Group therapy; i. Substance abuse counseling; j. Recreational therapy;



k. Vocational services and job coaching; l. Rehabilitation case manager; m. Nursing and pharmacology management; n. Brain injury specialist; and/or o. Follow-up interviews with family, which may include, home visits and phone

contacts. 4. Therapies, treatments and/or services are included in the per diem rate and are not

billed separately. VI. OUTPATIENT MEDICATION PRIOR AUTHORIZATION PROGRAM

A. Rules Pertaining To Pharmacy Benefits 1. OAC 4123-6-21 - Payment for outpatient medication 2. OAC 4123-6-21.1 - Payment for outpatient medication by self-insuring employer 3. OAC 4123-6-21.2 - Pharmacy and therapeutics committee 4. OAC 4123-6-21.3 - Outpatient medication formulary and Appendix to the Formulary

List of Medications Covered by BWC 5. OAC 4123-6-21.4 – Coordinated services program 6. OAC 4123-6-21.5 - Standard Dose Tapering Schedule and Appendix to Weaning List 7. OAC 4123-6-21.6 - First Fill Program and Appendix to the First Fill Drug List 8. OAC 4123-6-21.7 – Opioid Prescribing

B. Pharmacy Benefits Manager

1. BWC has a Pharmacy Benefits Manager who processes outpatient medication bills for state-fund, Black Lung and Marine Industry Fund claims. The Pharmacy Benefits Manager is a single source for accepting and adjudicating prescription drug bills and is separate from the MCO. This program does not apply to self-insured employers. Questions related to self–insured claims should be referred to the injured worker’s employer. Please refer to OAC 4123-6-21.1 for additional information regarding self-insured claims.

2. Pharmacy Benefits Manager’s responsibilities are: a. Performing on-line, point-of-service adjudication of outpatient medication bills

with prescription information transmitted electronically between a pharmacy and Pharmacy Benefits Manager;

b. Enrolling pharmacy providers in a BWC-specific network; c. Processing prescription bills based on the BWC formulary list of covered

medications and restrictions; d. Utilizing drug relatedness editing for prescribed medications; and e. Performing desktop and on-site prescription audits of pharmacies.

3. BWC’s Pharmacy Benefits Manager does not reimburse for durable medical equipment or medical supplies purchased at a pharmacy. The injured worker’s MCO needs to be contacted regarding these services. Use the following options to contact the correct MCO using the injured worker’s claim number: a. The employer/MCO look-up on the BWC Web site is located at

https://www.bwc.ohio.gov/employer/services/EmployerMCOLookup/nlbwc/employermcolookup0.aspx;

b. The MCO directory brochure on the BWC Web site is located at https://www.bwc.ohio.gov/provider/brochureware/MCOUpdate/default.asp; and

c. A BWC Call Center Agent can be reached at 1-800-644-6292, option 0–3-0.

http://codes.ohio.gov/oac/4123-6-21

http://codes.ohio.gov/oac/4123-6-21.1v1





https://www.bwc.ohio.gov/downloads/blankpdf/OAC4123-6-21.5Appendix.pdf


https://www.bwc.ohio.gov/downloads/blankpdf/OAC4123-6-21.6Appendix.pdf



https://www.bwc.ohio.gov/employer/services/EmployerMCOLookup/nlbwc/employermcolookup0.aspx

https://www.bwc.ohio.gov/employer/services/EmployerMCOLookup/nlbwc/employermcolookup0.aspx

https://www.bwc.ohio.gov/provider/brochureware/MCOUpdate/default.asp



C. Prior Authorization 1. BWC requires prior authorization for certain drugs not typically used to treat work-

related injuries or illnesses when a condition is not allowed in the claim that supports the Food and Drug Administration’s approved uses of that prescribed drug. The prescribing physician must complete the Request for Prior Authorization of Medication Form (MEDCO-31) to request prior authorization. Please log on the following Web site to access the MEDCO-31: https://www.bwc.ohio.gov/provider/services/PharmacyBenefits/priorauth.asp.

2. BWC requires prior authorization for: a. Medical Only claims beyond sixty (60) days from the date of injury; b. All claims beyond two-hundred seventy (270) days of last paid prescription; and c. A pending surgery.

i. A physician can submit a MEDCO-31 to request pain medication or other post-surgically related medications subsequent to the MCO approval yet prior to the surgery date.

ii. The surgery date must be included on the MEDCO-31 for consideration. iii. A mediation request of this type would be limited to a thirty (30) day fill.

3. To access BWC’s formulary covered drugs, restrictions and prior authorization visit our website at https://www.bwc.ohio.gov/provider/services/ICD10FormularyLookup/Default.aspx.

D. Generic & Brand Name Drugs 1. An injured worker who request a brand name drug for a medication, which has an

equivalent generic product available, shall have the following options: a. The physician will prescribes a different drug; and/or b. The brand name drug is dispensed and the injured worker pays the difference in

price between the generic price and the brand name drug requested. 2. The injured worker shall be responsible for the cost difference between the price of

the generic product and the average wholesale price plus or minus BWC’s established percentage of the dispensed brand name drug, if the physician writes: a. “Dispense as written” or “DAW” on the prescription; or b. Indicates the brand name form of the prescribed drug is “medically necessary.”

E. Injectable & Compounded Medication

1. A compounded medication is a combination of drugs (compounded) BWC requires to be dispensed by a licensed pharmacy provider. These medications contain pharmaceuticals in dosage forms and combinations that are not commercially available. Compounded medications have a National Drug Code (NDC) number for each ingredient that is included in the compounded product, and Pharmacy Benefits Manager Fee Schedule pricing is applied. The Pharmacy Benefits Manager Fee Schedule is not published because it is proprietary.

2. All compounded medications require prior authorization via the MEDCO-31. 3. All outpatient self-injectable and compounded medications shall be obtained from a

licensed pharmacy provider. The pharmacy electronically bills the Pharmacy Benefits Manager for payment.

https://www.fda.gov/

https://www.bwc.ohio.gov/downloads/blankpdf/medco-31.pdf



https://www.bwc.ohio.gov/provider/services/PharmacyBenefits/priorauth.asp



https://www.bwc.ohio.gov/provider/services/ICD10FormularyLookup/Default.aspx




F. Covered Services 1. BWC shall only reimburse for:

a. Medications for the treatment of an allowed injury or illness; b. Medications prescribed by the treating physician or physician of record; c. Medications listed in the appendix to the formulary or widely accepted to treat an

injury; and d. Food and Drug Administration approved legend and over-the-counter drugs.

2. The prescribing physician may verify the allowed conditions in a claim by visiting our website at www.bwc.ohio.gov or by calling 1-800-644-6292.

G. Billing

1. Existing Claims a. A pharmacy provider is required to submit bills for outpatient medications at the

point-of-service in all claims, including situations prior to assigning a BWC claim number. In order to submit a bill at the point-of-service, the pharmacist must transmit at least two (2) of the following three (3) items, along with the other billing information, to the Pharmacy Benefits Manager: i. BWC claim number; ii. Social Security number; and/or iii. Date of injury.

b. The Pharmacy Benefits Manager shall verify the information, process the bill and send the pharmacist an appropriate message based on the claim’s status, allowed conditions and formulary coverage and restrictions.

c. The Pharmacy Benefits Manager shall pay pharmacy provider bills according to the Pharmacy Benefits Manager Fee Schedule.

d. Medications administered at a skilled nursing facility must be obtained from a licensed pharmacy provider that electronically submits the bill(s) to the Pharmacy Benefits Manager for payment, and delivers the medication to the facility for administration.

2. First Fill Program: a. BWC has established a program to provide reimbursement for the first fill of

prescription drugs for medical conditions identified in a pending workers’ compensation claim. The program is limited to the first fill list (click here) of prescription drugs that occur prior to the date BWC issues an initial claim determination order.

b. Prescription reimbursement is limited to the following: i. A period of ten (10) days or less at the most commonly prescribed dosing

schedule, and no refills shall be approved; ii. One (1) drug per therapeutic drug class listed in the appendix to OAC 4123-

6-21.3; iii. Extemporaneous compounded prescriptions are not eligible for

reimbursement under the first fill program; and; c. Prescription drugs listed in the appendix to OAC 4123-6-21.3 along with the

maximum quantity of each. Prescription drugs not listed in the appendix to OAC 4123-6-21.3 are not eligible for reimbursement unless prior authorization was approved by BWC.


http://www.bwc.ohio.gov/

http://codes.ohio.gov/pdf/oh/admin/2017/4123-6-21$6_PH_FF_N_APP1_20141230_0808.pdf








d. The prescribing physician or the prescribing physician’s agent must write 'work-related injury' on and sign the prescription in order for the prescription to be eligible for the first fill program. The pharmacist and pharmacy intern is permitted to write the phrase and sign telephone prescriptions. BWC shall guarantee payment for reimbursement for prescription drugs to a pharmacy provider when the first fill program requirements are followed, regardless of final claim acceptance or denial.

e. First fill prescriptions are reimbursed in the same manner as other prescriptions. The pharmacy provider should follow the steps outlined above in the existing claims section for guidelines. Custom messaging shall direct the pharmacy provider to resubmit the prescription after consulting the first fill medication list to ensure coverage..

H. Reimbursement Rates

1. Please refer to OAC 4123-6-21 for reimbursement rates and/or calculations for state-fund employers for the following: a. Single Source/Brand Drug; b. Multi-Source/Generic Drug; and c. Compounded product-dispensing fees for non-sterile and sterile compounds (i.e.,

Pharmacy Benefits Manager Fee Schedule pricing is applied per ingredient within the compounded product based on Single Source/Brand Drug and/or Multi-Source/Generic Drug); and

d. The maximum reimbursement for any one (1) compounded prescription. 2. It is important to note that BWC does not distinguish between legend and over the

counter medications when determining reimbursement. Over the counter drugs must be prescribed by a provider licensed to prescribe medications in order for the drug to be considered for reimbursement.

3. The state fund (OAC 4123-6-21) and self-insuring employer’s (OAC 4123-6-21.1) pharmacy rules both state how the product cost component of payment for prescription drugs must be calculated. Furthermore, the self-insured reimbursement rate shall be consistent with the state fund rate.

4. The self-insuring employer or the self-insuring contracted Pharmacy Benefits Manager, vendor may negotiate a lower or higher rate with the pharmacy provider; however, the pharmacy provider that does not enter into such agreements is entitled to payment at the Pharmacy Benefits Manager Fee Schedule amount and under no circumstances may the injured worker be balance billed by the provider. The self-insured employer cannot unilaterally impose a lower fee schedule than the amount allowed under the Pharmacy Benefits Manager Fee Schedule.

5. Relatedness editing may not apply to self-insured employers.

I. Supply & Quantity Limits - BWC established maximum days supply and maximum quantity limits for both standard and catastrophic/chronic claim types. 1. A standard claim can only receive the greater of a thirty-four (34) day supply or one-

hundred twenty (120) units per dispensing. 2. Catastrophic claims may receive up to a ninety (90) day supply with no quantity

limitations.






J. Forms 1. The prescribing physician uses the MEDCO-31 form to request prior authorization for

medications not typically used for industrial injuries or occupational disease. Please fax completed MEDCO-31 forms to 1-866-213-6066.

2. The physician uses the Formulary Medication Request Form (MEDCO-35) to ask the Pharmacy & Therapeutics Committee to consider additions or deletions of a particular drug to the formulary.

3. The injured worker should use the Request for Injured Worker Outpatient Medication Reimbursement (C-17) to obtain reimbursement for prescribed outpatient medication only. This form is not used for medical supplies, durable medical equipment (e.g., crutches, walkers) and other non-drug items regardless of the prescribing provider. The pharmacy provider is expected to submit bills electronically, even before the injured worker has a claim number. As a result, the use of the C-17 should be rare and limited to special circumstances. The injured worker can obtain all the information the injured worker needs to complete the form from the injured worker’s pharmacy provider. The completed C-17 forms shall be submitted to the Pharmacy Benefits Manager with the medication labels, pricing information or a pharmacy printout with pricing information and the pharmacist’s signature. For billing instructions on the C-17, please refer to Billing Instructions, Chapter 4 of this manual. a. The invoice must be mailed to the Pharmacy Benefits Manager. b. The mailing address information and instructions are located on the C-17.

4. It is important to note that an injured worker whose employer is self-insuring should contact the inured worker’s employer for instructions on billing for outpatient medications. The Pharmacy Benefits Manager is not responsible for processing bills in self-insuring claims.

5. The Service Invoice (C-19) or CMS-1500 forms are important because the MCO determines reimbursement eligibility for durable medical equipment and disposable medical supply services obtained in a pharmacy. a. Contact the MCO for specific requirements for the use of the C-19 and CMS-

1500. b. BWC shall accept either the 08/05 or the 2/20/12 version of the CMS-1500 since

BWC is not a covered entity under the Health Insurance Portability and Accountability Act.

K. Contacts

1. The Pharmacy Benefits Manager is prepared to answer technical support inquiries from the pharmacy provider and inquiries from the injured worker regarding the status of a submitted C-17. To contact the Pharmacy Benefits Manager call 1-800-644-6292, and follow the prompts.

2. BWC Pharmacy Department: Providers, injured workers, employers and their representatives can inquire about the Prior Authorization Program or other drug coverage related questions by calling 1-877-543-6446 or 1-800-644-6292 and follow the prompts.

3. Questions and comments about pharmacy benefits should be emailed to the [email protected] or by mail to: Ohio Bureau of Workers’ Compensation, Pharmacy Department, 30 W. Spring St. L-21, Columbus, OH 43215-2256.













mailto:[email protected]



VII. HOME HEALTH AGENCY SERVICES

A. Eligible Providers - To be enrolled and certified by BWC, home health agencies must be either: 1. Certified by Medicare; 2. Accredited by the Joint Commission; 3. Accredited by Community Health Accreditation Program; or 4. Accredited through an organization granted deeming authority by Medicare.

B. Services 1. Skilled Nursing, Hourly Nursing, Home Health Aides, Therapists, and Social Workers

a. Billing for home health services must be submitted to the MCO on a CMS-1500 using the appropriate HCPCS Level I (CPT®) codes for physical, occupational or speech therapy and HCPCS Level II or BWC local level codes, listed in Chapter 2 of this manual, for other services including skilled nursing visits, hourly nursing, home health aide, and social worker visits.

b. Note: Skilled nursing visits include initial assessment and up to two (2) hours/day. Thereafter, services are paid per fifteen (15) minute increments. Time documentation shall be included in all notes.

2. Mileage and Travel Time a. The following codes are specific to services provided by home health agencies.

i. W2704 Home health agency worker providing direct care, mileage per mile, beginning with 51st mile round trip.

ii. W2705 Travel time, home health agency professional worker each six (6) minutes

iii. W2706 Travel time, home health agency non-professional worker each six (6) minutes

b. The MCO shall select the BWC certified Home Health Agency that is closest to the injured worker’s residence. i. Payment of mileage and/or travel time is limited to home health agency

workers who are providing direct care to the injured worker. ii. Mileage shall be reimbursed beginning with the 51st mile for a round trip for

an injured worker. iii. Mileage and time are calculated as follows:

a) Mileage and/or time calculation begins from home health worker’s home base to injured worker home, and ends with return trip from injured worker home to home health worker’s home base or next injured worker whichever comes first; or

b) Mileage and/or time begins from home health workers previous point of service to injured worker home and ends with return trip from injured worker home to home health worker’s home base or next injured worker whichever comes first.

c. Note: Mileage and travel time codes may not be billed in conjunction with the all-inclusive per diem home infusion therapy codes or hospice codes.

3. Home Infusion Therapy a. The MCO shall negotiate a per diem rate for all home infusion, therapy services

while still maintaining high quality care for the injured worker. This rate shall include nursing services, medical supplies, medication and pharmacy services, unless otherwise noted. (See VII.B.3.b.iii. below)



b. The all-inclusive per diem rates may be negotiated with the following BWC infusion pharmacy provider: i. A Medicare certified (i.e., issued by the Centers for Medicare and Medicaid

Services directly or a Medicare ‘deeming’ organization) or Joint Commission accredited home health agency which has its own state pharmacy board licensed fluid therapy pharmacy; or

ii. A state pharmacy board licensed fluid therapy pharmacy, which holds Joint Commission accreditation as a certified home infusion therapy provider with nurses either employed by the pharmacy or contracted by the pharmacy through a Medicare certified or Joint Commission accredited home health agency.

iii. In some instances, it may be necessary for pharmacy services and skilled nursing services to be billed separately if a nursing agency is being used in addition to the infusion pharmacy. The pharmacy per diem charge shall include all services and supplies except for skilled nursing visits. The home health agency shall bill for each skilled nursing visit, and must be BWC certified.

c. The MCO’s negotiated per diem rates shall be equal to or lower than the BWC fees for the individual components. Billing for home infusion therapy must be submitted to the MCO on a CMS-1500. BWC recognizes the following BWC local level codes for billing of home infusion therapy: i. W9010 - all-inclusive per diem, parenteral nutrition therapy; ii. W9020 – all-inclusive per diem, enteral nutrition therapy; iii. W9030 - all-inclusive per diem, antibiotic home infusion therapy; iv. W9040 - all-inclusive per diem, pain management home infusion therapy; v. W9050 - all-inclusive per diem, fluid replacement home infusion therapy; vi. W9060 - all-inclusive per diem, chemotherapy home infusion therapy; vii. W9070 - all-inclusive per diem, multiple home infusion therapies; and viii. W9075 – home infusion therapy, includes nursing and medical supplies only.

4. Hospice Services a. BWC enrolls hospice providers as Provider Type 30 - Home Health Agency.

Hospices must be licensed by the state and be Medicare/Medicaid certified to become providers. Criteria for hospice services eligibility includes: i. Request for hospice care must be at physician of record direction; ii. The need for hospice care must be directly related to the claim allowance; iii. The injured worker must be terminally ill with an estimated life expectancy of

less than six (6) months; iv. Aggressive treatment is no longer occurring. All future treatment shall be

palliative (for the comfort of the patient). b. Services shall receive authorization for no more than ninety (90) days at a time.

All services and supplies must be provided for patient comfort rather than for treatment. i. In home hospice care, that includes all services and supplies necessary for

the injured worker’s comfort may include nursing care, counseling services, massage, art, music, bereavement therapies, and supplies.

ii. Respite hospice care that may be provided in hospice facilities or in nursing homes or hospitals with which the hospice provider has a contract to provide respite care.



iii. Acute hospice care for symptom management in hospice facilities or in nursing homes or hospitals with which the hospice provider has a contract to provide acute pain management services.

c. BWC shall reimburse for all services and supplies to the hospice provider at an all-inclusive per diem rate. The per diem rate is paid regardless of the number of services or the time spent providing those services, but it is expected that the hospice provider meets all injured worker needs. BWC shall not approve additional home health services. The following codes are billed to the MCO by the hospice provider and then the hospice provider is responsible for reimbursing the nursing home, hospital, etc., with which it has a contract: i. Z0500 – in home hospice care per diem; ii. Z0550 – respite hospice care per diem; and iii. Z0560 – acute hospice hospital care for pain management per diem.

C. Billing Requirements - Billing for home health services must be submitted to the MCO on

a CMS-1500 using the appropriate HCPCS Level I (CPT®) or HCPCS Level II or BWC local level codes.

VIII. NURSING HOME AND (LOCATED IN SECTION - NEW-REVISED-UPDATED POLICIES OF THE PBRM)

IX. RESIDENTIAL CARE/ASSISTED LIVING FACILITY BILLING REQUIREMENTS POLICY (LOCATED IN SECTION - NEW-REVISED-UPDATED POLICIES OF THE PBRM)

X. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) & NEURO-

MUSCULAR ELECTRICAL NERVE STIMULATION (NMES) - The intent of the BWC “TENS and NMES” policy is to implement minimum standards for all vendors supplying TENS and NMES units to Ohio’s injured workers and to establish standardized criteria for the medical indications for the use of TENS and NMES.

A. ORC 4752.02(A) - Pursuant to ORC 4752.02(A), no person shall provide home medical

equipment services unless they have a valid license or certificate of registration from the Ohio Respiratory Care Board. This includes TENS units. All in-state BWC-certified durable medical equipment providers already have the mandatory license/certificate, as this is required to obtain BWC certification. ORC 4752.02 exempts the following from the licensure/certification requirement: 1. Orthotist; 2. Prosthetist; 3. Pedorthist; and 4. The hospital providing home medical equipment, as an integral part of patient care

and not through a separate entity that has its own Medicare or Medicaid provider number from this licensure/registration requirement, is included in this listing.

B. OAC 4123-6-43 - Per TENS rule OAC 4123-6-43, BWC does not reimburse for devices

that are labeled by the Food and Drug Administration for over-the-counter use and are identified with the Food and Drug Administration product code “NUH.OTC.TENS.”

C. Definitions For TENS & NMES

1. TENS is a device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the injured worker’s perception of pain by inhibiting the afferent pain nerve impulses and/or stimulating the release of endorphins.

https://www.bwc.ohio.gov/basics/PolicyLibrary/FileShell.aspx?file=%2fMedical+Policy%2fTENS+and+NMES.htm

http://codes.ohio.gov/orc/4752.02


http://www.respiratorycare.ohio.gov/








2. NMES is a device, which transmits an electrical stimulus to muscle groups and causes the muscle to contract.

D. Required Criteria For TENS & NMES Units - This criteria applies to all vendors supplying

TENS and NMES units to Ohio’s injured workers: 1. BWC Minimum Technical & Educational Criteria

a. TENS and NMES units Requirements i. Device must produce constant current. ii. Device must be restricted to prescription use only; no over-the-counter

devices. b. Rationale

i. Constant current maintains waveform as it is driven through the skin. It allows the current to be delivered in a uniform pattern, increasing the comfort level for the injured worker. Breakdown of the waveform may result in increased skin irritation and burning.

ii. Per BWC TENS rule OAC 4123-6-43(D), BWC shall not pay for the rental or sale of devices that are labeled by the Food and Drug Administration for over-the-counter use and are identified with the Food and Drug Administration product code "NUH.OTC.TENS."

iii. Also, as it relates to NUH OTC TENS units, BWC TENS rule OAC 4123-6-43(A)(1) provides that TENS units shall only be purchased for use by the injured worker following a required thirty-day rental period. Because NUH OTC TENS units cannot be rented prior to purchase, the MCOs shall not approve payment for NUH OTC TENS units.

c. Instruction/Education i. Requirements

a) TENS and NMES units supplied by a practitioner must be personally fitted and face-to-face instruction provided when the unit is supplied.

b) Documentation of this instruction must be in the injured worker’s record. c) TENS and NMES units provided by a durable medical equipment supplier

must be personally fitted and face-to-face instruction given by a direct employee of the durable medical equipment provider within five (5) business days of the request for the unit, at no additional charge. If the durable medical equipment verifies and documents that the ordering practitioner is supplying the instruction/education, the durable medical equipment is not required to do so.

d) This verification documentation should be available to BWC or the MCO upon request.

ii. Rationale – The injured worker is more apt to use the TENS or NMES unit correctly and to have fewer problems and increased pain relief if given face-to-face instruction rather than if given written or telephonic instruction.

d. Supplies Requirement: i. The injured worker’s MCO shall regularly determine the specific TENS

supplies needed by the injured worker throughout the timeframe authorized for TENS use.

ii. The TENS provider must receive authorization from the injured worker’s MCO prior to the delivery of supplies and/or equipment.








iii. The TENS provider shall then deliver the supplies and bill the injured worker’s MCO after authorization is received.

iv. A self-insuring employer may, but is not required to, follow the same procedure as an MCO under this rule; provided, however, that in no event shall a self-insuring employer require an injured worker to submit a written request for TENS supplies and/or equipment.

v. The injured worker’s MCO shall retain documentation of the contact with the injured worker substantiating the injured worker need for supplies in accordance with the periods set forth in OAC 4123-6-14.1.

vi. The TENS provider’s bill must indicate the actual date of service, reflecting the date that services or supplies were provided.

vii. BWC, the MCO, Qualified Health Plans or self-insuring employer may adjust bills upon audit if the audit discloses the provider’s failure to comply with this rule.

viii. The TENS provider shall maintain the following records and make them available for audit upon request: a) Authorizations of TENS supplies or equipment received from the injured

worker’s MCO and all other documentation relating to the injured worker need for TENS supplies or equipment received by the provider prior to the delivery of the supplies or equipment, including any requests received from the injured worker, if applicable;

b) Records of the provider's wholesale purchase of TENS supplies or equipment; and

c) Records of delivery of supplies to injured workers and of the delivery or return of TENS units.

d) Upon request, the provider shall supply copies of the record information to the requester at no cost. Failure to provide the requested records may result in denial or adjustment of bills related to these records.

e. Rationale i. Appropriate amounts of medically necessary supplies shall be provided. ii. The billing provider shall not issue supplies unless the injured worker’s MCO

has provided authorization. 2. BWC Medical Necessity Criteria

a. TENS for Chronic Pain i. Prior authorization by BWC, the MCO or self-insured employer or their agents

is required for TENS rental or purchase. ii. Payment for a transcutaneous electrical nerve stimulator (i.e., TENS) is

covered for the treatment of an injured worker with chronic, intractable pain who meets the following criteria: a) Documentation of chronic pain that has been present for three (3)

months; b) Documentation of the location of pain, duration of time the injured worker

has had pain, and the presumed cause of the pain; and c) Documentation of other modalities that have been tried and failed.

iii. A trial rental period at a minimum of one (1) month is implemented to determine the effectiveness of TENS unit. The following documentation must be present in the physician’s records at the conclusion of the thirty (30) day trial period to purchase a TENS unit for chronic pain: a) Frequency and duration of use of TENS; and b) Results of TENS units modulating pain.




b. TENS for Acute Post-operative Pain i. TENS rental is generally limited to thirty (30) days beyond surgery. ii. For reimbursement beyond thirty (30) days, the physician must provide

medical documentation for justification. c. NMES

i. A NMES device provides an electrical stimulus directly to the muscle or motor nerve of the muscle, causing the muscle to contract. The goal is to stimulate denervated muscle to prevent atrophy or degeneration and to strengthen/train healthy muscles that are at risk of atrophy from immobilization or disuse due to injury. Prior authorization by BWC, the MCO or self-insured employer or their agents is required prior to NMES rental or purchase.

ii. The MCO Medical Director or an MCO physician consultant is required to review each request for home rental or purchase of NMES based on medical necessity and BWC NMES criteria.

iii. Reimbursement of NMES devices for home use for the treatment/prevention of muscle atrophy requires the following conditions be met: a) The injured worker has suffered partial or complete loss of function in one

(1) or more muscles because of an injury to a peripheral nerve or nerve root; and

b) Denervation is substantiated by electromyography confirming the nerve injury. The electromyography must demonstrate positive waves and/or fibrillation in the affected muscles.

iv. BWC and the MCO shall reimburse NMES and functional electrical stimulation to enhance walking of injured workers with spinal cord injuries who meet all the following criteria: a) Diagnosis of paraplegia of both lower limbs; b) Willingness to use the device on a long-term basis; c) High motivation, commitment and cognitive ability to use the device for

walking; d) Completion of a physical therapy training program of a minimum of thirty

(30) sessions with the NMES unit over a three (3) month period; e) Intact lower motor units (i.e., L1 and below) both muscle and peripheral

nerve; f) Demonstration of brisk muscle contraction to NMES and sensory

perception of electrical stimulations sufficient for muscle contraction; g) Muscle and joint stability for weight bearing at upper and lower

extremities with demonstration of balance and control to maintain an upright support posture independently;

h) Ability to transfer independently and demonstration of standing independently for at least three (3) minutes;

i) Demonstration of hand and finger function to manipulate controls; j) Minimum of six (6) month post recovery spinal cord injury and restorative

surgery; and k) Absence of hip and knee degenerative disease and no history of long

bone fracture secondary to osteoporosis. v. The appropriate HCPCS Level I (CPT®) code to be billed to MCO or the

BWC for the required physical therapy with the NMES unit is 97116-gait training.

vi. NMES/functional electrical stimulation for walking is contraindicated for spinal cord injured workers with any of the following:



a) Cardiac pacemakers or cardiac defibrillators; b) Severe scoliosis or severe osteoporosis; c) Irreversible contracture; d) Autonomic dysreflexia; or e) Skin disease or cancer at the area of stimulation.

E. OAC 4123-6-43 - Payment Of Transcutaneous Electrical Nerve Stimulators &

Neuromuscular Electrical Stimulators 1. Payment shall be approved for a TENS unit for treatment of allowed conditions in a

claim directly resulting from an allowed industrial injury or occupational disease, as provided in OAC 4123-6-43 and in this manual.

2. Prior authorization is required to have a prescribed transcutaneous electrical nerve stimulator unit and supplies furnished to the injured worker.

3. Each injured worker who requires a TENS unit shall be provided only one (1) unit at a time.

4. For each TENS unit request approved, the unit shall be rented for a trial period of thirty (30) days before purchase of the TENS unit. This trial period is to evaluate the medical necessity and effectiveness of the TENS treatment.

5. All rental payments for the TENS unit shall be applied to the purchase price. 6. A TENS unit, furnished and purchased for the injured worker, is not the personal

property of the injured worker, but remains the property of BWC or self-insuring employer.

7. At its discretion, BWC or self-insuring employer reserves the right to reclaim and recover the TENS unit from the injured worker at the completion of the course of TENS treatment.

8. Once a TENS unit is purchased, BWC or self-insuring employer shall reimburse for repair or replacement, upon the submission of a request from the physician of record or treating provider that includes medical documentation substantiating the continued medical necessity and effectiveness of the unit.

9. Please note that the above criteria listed in OAC 4123-6-43 Payment of Transcutaneous Electrical Nerve Stimulators, also apply to the payment of neuromuscular units (i.e., NMES).

F. Coding & Reimbursement Of TENS/NMES 1. BWC shall not separately reimburse for a TENS/NMES fitting and instruction. Fee

for TENS and NMES units includes fitting and instruction. Please refer to the most current medical and Professional Provider Fee Schedule for reimbursement rates.

2. Current fee schedules are published at https://www.bwc.ohio.gov/provider/services/agreement.asp.

Code Description

E0720 TENS unit, 2 lead (rent to purchase) E0730 TENS unit, 4 lead (rent to purchase) E0731 Form fitting conductive garment, TENS or NMES A4595 All supplies for TENS and NMES except lead wires and

batteries, per month E0745 NMES unit (rent to purchase) A4557 Lead wires, per pair

https://www.ohiobwc.com/downloads/blankpdf/OAC4123-6-43.pdf




https://www.bwc.ohio.gov/provider/services/agreement.asp



XI. LOW LEVEL LASER THERAPY - BWC’s review of the medical literature determined there is inadequate evidence to support the medical effectiveness of low level laser therapy for the treatment of musculoskeletal disorders. See the BWC position paper on our Web site, https://www.bwc.ohio.gov/downloads/blankpdf/PositionLaserTherapy.pdf.

XII. OTHER BWC CERTIFIED PROVIDER SERVICES

A. Billing From All Other BWC Certified Providers - Billing from all other BWC certified

providers, including, but not limited to, ambulance, durable medical equipment supplier, orthotist, prosthetist and traumatic brain injury facilities must be submitted to the MCO on a CMS-1500 using the appropriate HCPCS Level I (CPT®) or HCPCS Level II codes or BWC local level codes.

B. Medical Services Request – A physician of record or treating provider must submit a

request for medical services because these services require prior authorization. Please refer to Signature on Medical Evidence Grid, in section II.P.1.

C. Durable Medical Equipment

1. BWC follows HCPCS Level II to report durable medical equipment E0100-E9999. Durable medical equipment is defined as equipment which: a. Can withstand repeated use; b. Primarily and customarily serve a medical purpose; c. Generally is not useful to a person in the absence of illness or injury; d. Is appropriate for use in the home; and e. Does not include disposable items.

2. The following reusable items are examples of durable medical equipment: a. Hospital beds; b. Mattresses for hospital beds; c. Walkers; d. Wheelchairs; e. Breathing machines; f. Crutches; g. Bedside commodes; and h. Seat-lift mechanism.

3. BWC considers a seat-lift mechanism to be medically necessary for injured workers who require a mobility aid to stand from a seated position due to physical limitations that are reasonably related to the industrial injury (i.e., disease). BWC reimburses the seat-lift mechanism, (i.e., E0627, E0628 or E0629) when the MCO determines it is medically necessary and appropriate to the industrial injury. BWC does not reimburse the chair (i.e., furniture).

4. BWC shall not reimburse for equipment, used primarily and customarily for non-medical purposes, because it does not qualify as durable medical equipment. Pursuant to OAC 4123-6-07, the following items are never covered by BWC: a. Home furniture including, but not limited to: reclining chairs, non-hospital beds,

water beds, lounge beds (e.g., Adjust-A-Sleep Adjustable Bed, Craftmatic Adjustable Bed, Electropedic Adjustable Bed, Simmons Beautyrest Adjustable Bed);

b. A mattress for a non-hospital bed; c. Home exercise equipment including but not limited to such equipment as

treadmills and exercise bikes; and

https://www.bwc.ohio.gov/downloads/blankpdf/PositionLaserTherapy.pdf




d. Home whirlpools including built-in whirlpools and pumps, portable hydrotherapy pools, jacuzzi tubs, portable saunas and spas and TheraSaunas are not considered to be medically necessary. When a request is received for a built in hot tub/whirlpool, the MCO shall call the provider to advise that BWC covers the “over tub whirlpool” (i.e., E1300) if determined to be medically necessary and appropriate to the industrial injury.

5. Specific features of durable medical equipment that have been determined by the MCO to be features that are not medically necessary or do not have a reasonable relationship to the allowed conditions in the claim shall not be reimbursed. Examples include: a. Heavy duty/bariatric piece of equipment, unless the injured worker meets the

weight requirements; b. Limited reimbursement of a hospital bed mattress to a single size mattress, or

the size that is required by the injured worker determined by the injured worker’s weight, height and medical condition. BWC shall not reimburse a provided for a double, queen or king size mattress to accommodate two (2) people; or

c. BWC shall not reimburse a provider for a “deluxe” model if the standard model provides the features that are medically necessary for the injured worker.

6. BWC considers durable medical equipment to be purchased when rental has reached the BWC purchase fee. BWC does not accept a provider’s percentage reduction from the rental fees already paid which result in BWC payment of additional monies for the purchase of the equipment beyond the BWC purchase fee.

D. Equipment Used As Part Of A Surgical Procedure

1. Equipment used as part of a surgical procedure (i.e. implantable devices, surgical hardware) must be billed by the facility where the procedure takes place (i.e., ambulatory surgical center or hospital) or by the physician if done in the physician’s office.

2. BWC and the MCO shall not reimburse the manufacturer or supplier of the equipment when the equipment is used as part of a surgical procedure.

3. Replacement batteries for implanted devices shall be reimbursed to the attending provider or durable medical equipment supplier.

4. Examples of equipment used as part of a surgical procedure include, but are not limited to: implantable neurostimulator pulse generator, implantable neurostimulator electrodes, implant hardware, implantable infusion pump and implantable intraspinal catheter.

XIII. SERVICES APPROVED AND REIMBURSED BY BWC RATHER THAN BY

THE MCO

A. Caregiver Services 1. A caregiver not employed by BWC certified home health agencies who was

initially approved for services prior to December 14, 1992 (i.e., January 9, 1995 for spouse caregivers) may continue providing the services if approved by BWC.

2. Billing must be submitted directly to BWC rather than to an MCO. 3. The caregivers should not bill for dates the injured worker was hospitalized,

as those dates are not reimbursable. 4. The BWC Service Office assigned to the claim shall perform annual review

and renewal of caregiver services authorization.



5. Per OAC 4123-6-38.1, in the event the caregiver is no longer able to provide services, no replacement caregivers are allowed. A BWC certified home health agency must provide further services.

B. Home & Vehicle Modifications

1. When the provider submits a request for home and/or vehicle modifications, the MCO shall respond to the provider and injured worker in writing, according to Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) form processing periods, that the request is being forwarded to the specific BWC Catastrophic Nurse Advocate. a. The BWC Catastrophic Nurse Advocate shall address all home and vehicle

modification requests for all claims regardless if the equipment being requested is for a catastrophic claim and shall issue a determination.

b. The BWC Catastrophic Nurse Advocate shall work closely with the MCO case manager and the necessary vendors to ensure coordination of the services.

c. If the MCO receives a request for other services/supplies on the same C-9, the MCO shall review and respond to the non-home and vehicle modification services request within the C-9 processing timeframes.

2. The BWC Catastrophic Nurse Advocate is the primary authorization source for home and vehicle evaluations and modifications. a. Reimbursement of home and vehicle modification services is made by either

BWC or the MCO depending upon specific service and provider type. b. Actual home and vehicle modifications are:

i. Performed by a vendor; ii. Billed with a specific W code; and iii. Paid by BWC.

c. Other services provided by a vendor require W codes for billing. These services are paid by BWC. Exception: Scooter/wheelchair lift and installation (i.e., W4000 and W4001) including anchoring the lift to the vehicle or attachment of a hitch is authorized and paid by the MCO. An installation that requires additional vehicle modification requires review/authorization by BWC.

d. Services billed by outpatient hospital (e.g., driving evaluations and driving training) require the use of revenue codes with appropriate CPT codes and are paid by the MCO.

e. Services billed by inpatient hospital require revenue codes only and are paid by the MCO.

3. The list below outlines specific billing, coding, and reimbursement information:

Description of Service

Provider Type

HCPCS/CPT® Code

Revenue Code

Fee Billing form

Bill To

Driving evaluation PT, OT or certified driving instructor

Non-facility

W0500 NA By-Report C-19 or CMS-1500 (for facility)

BWC










Provider Type

HCPCS/CPT® Code

Revenue Code

Fee Billing form

Bill To

Driving evaluation

Facility Outpatient

97003 OT Hospital's outpatient reimbursement rate*

UB-04 MCO

Driving evaluation

Facility Outpatient

97001 PT Hospital's outpatient reimbursement rate*

UB-04 MCO

Driving instruction for modified vehicle- PT, OT or certified driving instructor

Non-facility

W0549 NA By-Report CMS-1500

BWC

Driving instruction for modified vehicle

Facility Outpatient

97535 PT Hospital's outpatient reimbursement rate*

UB-04 MCO

Driving instruction for modified vehicle

Facility Outpatient

97535 OT Hospital's outpatient reimbursement rate*

UB-04 MCO

PT/OT evaluation for home/vehicle modification

Non-facility

W0678 NA By-Report CMS-1500

BWC

Home Modification (includes permanent ramp)

Vendor W0675 NA By-Report C-19 or CMS-1500

BWC

Vehicle Modifications


BWC










Provider Type

HCPCS/CPT® Code

Revenue Code

Fee Billing form

Bill To

Home and Vehicle Modification Repairs


BWC

Portable Ramp Rental or Purchase

Vendor W0676 NA Current BWC Fee Schedule

C-19 or CMS-1500

BWC

Lift, vehicle, 3-4 wheeled chair, with manual swing;


C-19 or CMS-1500

MCO

Lift, vehicle, 3-4 wheeled chair, with motorized swing


C-19 or CMS-1500

MCO

4. In order to differentiate between the types of scooter lifts that are available, BWC

established the following codes: a. W4000: Lift, vehicle, 3-4 wheeled chair, with manual swing; and b. W4001: Lift, vehicle, 3-4 wheeled chair, with motorized swing.

5. BWC shall not reimburse a “deluxe” model of a scooter lift if the standard model provides the features that are medically necessary for the injured worker.

6. The MCO has been advised that the customer rebate offered by several auto manufacturers when a lift or ramp product is purchased with an eligible new vehicle should be applied to the purchase of the scooter lift. The MCO shall deduct the amount of the rebate from the established fee for the lift and installation.

C. Non-Covered Services

1. Non-Covered Services include: a. Swimming pools of any type; b. Hot tubs portable, freestanding or installed; c. Spas portable, freestanding or installed; d. Whirlpool baths portable, freestanding or installed; e. Jacuzzis portable, freestanding or installed; f. Central air conditioning or air-purification systems; g. Dismantling of constructed ramp; h. Removal, dismantling or transfer of home modifications; i. Reimbursement of routine maintenance contracts; and j. Home improvements that are of general utility and are not of direct medical benefit

to the injured worker (i.e. carpeting, roof repair). 2. A portable whirlpool device put in the injured worker’s tub can be approved/reimbursed

by the MCO as durable medical equipment, if medically necessary and related to the allowed claim condition.













D. Home Modifications 1. BWC shall reimburse home modifications specifically needed by the injured worker

due to physical limitations due to the result of allowed claim conditions. 2. BWC’s fee cap for home modifications is forty-thousand ($40,000) dollars. 3. BWC shall authorize home modifications on a one (1) time basis only. An exception

would be for a ramp, which must be replaced if deterioration has occurred. Home modifications shall be limited to the interior of a residence with exception of ramps, lifts, and platforms necessary for accessing and exiting the home. The residence to be modified must be owned by the injured worker or a member of the injured worker’s immediate family.

4. Bathroom - Only one bathroom shall be modified. Please contact BWC Catastrophic Nurse Advocate for specifics.

5. Kitchen - BWC may approve limited kitchen modifications for injured workers who are living alone. Please contact BWC Catastrophic Nurse Advocate for specifics.

6. Driveway/Sidewalk – BWC does not widen driveways to allow injured workers to drive up and get out of a vehicle. BWC may approve paving of an area of a driveway or sidewalk for providing an operable surface for a scooter or wheelchair. Air Conditioning/Air Purifying Systems - A physician review of the claim file may be completed to determine medical necessity. Pulmonary function studies are considered when the injured worker has an occupational disease affecting the cardiovascular or respiratory system. Quadriplegics may require a room air conditioner for body temperature consistency. If an injured worker desires central air conditioning for the entire home, BWC shall reimburse the percentage of cost for air conditioning for the injured worker’s room only. BWC shall authorize a room air conditioning unit. BWC does not reimburse central air conditioning for the whole house. Air purifiers should be the portable type. Only claims allowed for pulmonary conditions, quadriplegia and burns qualify for air conditioners and only claims with pulmonary conditions for air purifiers.

7. Handicap Accessible Home – If the injured worker chooses to purchase a new handicap accessible home, BWC shall reimburse limited amounts for items such as a special shower, widened doorways, ramps, etc. An itemized list of handicapped accessories should be obtained from the builder and submitted for review and authorization prior to purchase. Reimbursement shall be made after the house is built and the injured worker furnishes a copy of the deed/closure documentation showing ownership.

8. Elevator Or Stair-Lift – A stair-lift can be approved for an injured worker on an individual case-by-case basis, for example, in cases where the injured worker is unable to climb stairs and bathroom facilities are on the second floor. If an injured worker receives a stair-lift, a second manual wheelchair may be approved. It may be less expensive to provide a first floor bathroom rather than to install an elevator if the residence structure shall not accommodate a stair-lift. Elevators should only be approved when there are no other alternatives. Stair-lifts are not approved for basement access.

9. Ceiling installed lift tracking mechanism – The injured worker must ensure that the home structure can accommodate this equipment.

E. Vehicle Modifications 1. BWC requires a physician prescription or C-9 from the physician of record for vehicle

modifications and driving evaluation and training, if needed, stating medical necessity and the relationship to the allowed condition.




2. A complete driving evaluation for initial vehicle modifications by a certified driving instructor is also required. a. A vehicle modification, shall be considered by, the BWC Catastrophic Nurse

Advocate, no more frequently than once every five (5) years. A more frequent or additional modification to the vehicle may be considered only if medical documentation supports a change in the injured worker’s medical condition and justifies the need.

b. BWC shall modify one (1) vehicle only. The same vehicle shall be modified for the lifetime of vehicle. If an injured worker owns more than one (1) vehicle, the injured worker is responsible for modification of any additional vehicles.

c. The injured worker must undergo a driving evaluation if the vehicle is to be driven by the injured worker. BWC may require a second driving evaluation if there is a change in the injured worker’s condition.

d. BWC shall limit reimbursement to modification/equipment specifically needed by the injured worker. BWC shall not authorize luxury items. However, since quadriplegics cannot regulate their own body temperature and the atmosphere must be kept at a steady temperature, BWC may approve rear air conditioning and rear heat. BWC may authorize vehicle modifications for injured workers who utilize manual wheelchairs. Objective medical documentation must support the request.

e. BWC may authorize hand controls or left foot gas pedal for injured workers who utilize canes, crutches, or prostheses for mobility if objective medical documentation supports the need and driving evaluation recommends.

f. BWC shall not pay for purchase of the vehicle to be modified. g. BWC may authorize manual wheelchair carriers (e.g., car topper) for paraplegics

who can transfer. h. BWC may authorize modifications for allowed conditions requiring, a power

wheelchair for mobility or when the transfer of the injured worker is impossible to accomplish independently.

i. BWC shall reimburse for reasonable vehicle modification repairs, not routine maintenance of modified vehicles.

j. The injured worker is responsible for a yearly maintenance on lifts or mechanical parts.

k. Repairs of two-hundred fifty ($250) dollars or less do not require prior authorization by the BWC Catastrophic Nurse Advocate.

l. Repairs with an estimated cost greater than two-hundred fifty ($250) dollars require authorization by the BWC Catastrophic Nurse Advocate in advance unless done in emergency situation.

F. Prosthetics/Artificial Appliances

1. All eligible prosthetic/artificial appliance and repair thereof, whether for state fund claims or self-insured claims, are paid from the surplus fund. a. For MCO managed claims, the MCO receives the C-9 request for

authorization and approves or denies the request. If the request is approved, the provider submits the bill to the MCO.

b. In self-insured claims, BWC is responsible for processing requests for artificial appliance and travel expenses associated with the artificial appliance in all self-insured claims. When an artificial appliance is needed in a self-insured claim, the physician/provider must send a request for the artificial appliance and/or request for repair, as well as the subsequent bills, to the appropriate BWC Customer Service Team. The




BWC Customer Service Team must submit the bill from the provider to Medical Billing and Adjustments.

2. The provider must ensure that the following information is available for processing an artificial appliance request. Processing may be delayed if the following information is not included with the request: a. Written evidence that an artificial appliance has been determined to be medically

necessary for the injured worker from one (1) of the following: i. The Ohio State University hospital amputee clinic; ii. The Opportunities for Ohioans with Disabilities agency; iii. An amputee clinic approved by the administrator or the administrator’s

designee; and iv. A prescribing physician approved by the administrator or the administrator’s

designee. b. Dated and signed prescription for the item being requested including the

manufacturer, brand name and model number; c. Recent physical examination that includes a functional assessment with current

and expected ability, impact upon activities of daily living, assistive devices utilized and co-morbidities that impact the use of the prescribed artificial appliance;

d. Clinical rationale for requested artificial appliance, replacement part(s) or repair(s) and a description of any labor involved;

e. Coding description for the artificial appliance or repair utilizing the HCPCS (i.e., If a miscellaneous code is requested, all component items bundled in the miscellaneous code shall be listed along with a complete description and itemization of charges;

f. As appropriately required by the appendix to OAC 4123-6-08, a copy of the manufacturer’s invoice for items requested under a miscellaneous HCPCS code; and

g. Copy of any warranties related to the requested artificial appliance. 3. It is the prosthetist’s responsibility to assure that any prosthetic device/artificial

appliance fits properly for three (3) months from the date of dispensing. Any modifications, adjustments or replacements within the three (3) months are the responsibility of the prosthetist who supplied the item and BWC shall not reimburse for those services. The provision of these services by another provider shall not be separately reimbursed.

G. Interpreter Services

1. It is the policy of BWC to provide necessary and appropriate interpreter services for injured workers. Interpreter services are utilized for expediting treatment in catastrophic claims, purposes related to the filing or investigation of the claim purposes related to the allowed conditions in the claim, or medical specialist consultants requested by the physician of record or treating physician and approved by the managed care organization.

2. American Sign Language interpreters shall be provided, as necessary and appropriate, for routine office visits with the treating physician, meetings with durable medical equipment suppliers and during physical or occupational therapy. Foreign language interpreters shall not be provided for the above services and no interpreters shall be provided for hospital based services,




unless, after the BWC Claims Service Specialist or Disability Management Coordinator staffs the case with Claims, Medical or Rehab policy, an unusual situation exists which makes providing an interpreter necessary and appropriate.

3. Frequently, the injured worker shall arrange interpreter services from a friend, family member or other community resource. In some situations, an interpreter with special skills may be most appropriate (e.g., when the provider needs to relay complex medical information). If the injured worker is not able to arrange a friend, family member or community resource to interpret, or the arrangement does not appear adequate for the circumstances, the need for an interpreter must be addressed as soon as possible with the MCO. The MCO shall refer the need to the assigned BWC Claims Service Specialist or Disability Management Coordinator, who in consultation with the MCO shall determine what is “necessary and appropriate.” The BWC Claims Service Specialist or Disability Management Coordinator shall make the arrangements for an interpreter and notify the parties to the claim and the service provider of the approval or denial of interpreter services and the specific arrangements.

4. Please contact the MCO, BWC Claims Service Specialist or Disability Management Coordinator to request an interpreter. The assigned BWC Claims Service Specialist or Disability Management Coordinator is responsible for reviewing and approving interpreter services.

5. Interpreters For Hospital-Based Services a. Interpreter services in a hospital-based setting are the responsibility of the

hospital. b. If the injured worker has been approved for hospital-based services and

the BWC Claims Service Specialist or Disability Management Coordinator is aware that interpreter services shall be required, the BWC Claims Service Specialist or Disability Management Coordinator may notify the hospital social services or other department designated for obtaining interpreters of the need. In an effort to prevent interruption of care and facilitate return to work, the BWC Claims Service Specialist or Disability Management Coordinator may also request that the hospital notify them if interpreter services shall be required soon after the injured worker is discharged.

6. Interpreters for Vocational Rehabilitation a. When an injured worker is participating in vocational rehabilitation and it

appears interpreter services shall be required, the vocational rehabilitation case manager, MCO designee and BWC Disability Management Coordinator must staff the plan in advance.

b. The BWC Disability Management Coordinator has the responsibility to approve or disapprove the services prior to plan implementation.

c. Critical stages in the rehabilitation process when an interpreter may particularly be needed is during the initial interview with the injured worker, during discussion of and signing of the rehabilitation agreement, when the plan expectations are discussed with the injured worker, and if and when there is a change in the case direction.

7. Payment For Interpreter Services - Family members, friends, medical, health care and vocational providers and/or community volunteers may provide interpretation for injured worker s but are not eligible for enrollment or reimbursement.



a. BWC Medical Billing & Adjustments i. BWC Medical Billing and Adjustments must verify approval of all interpreter

services (BWC & IC) before processing the bill. ii. Interpreter services that are not approved by BWC or the IC shall be denied

for reimbursement using EOB 353 code, “Payment is denied as prior authorization is required for this service.”

b. Billing Instructions, Codes & Fees i. Current fees can be found on BWC's Web site at

https://www.bwc.ohio.gov/provider/services/agreement.asp. BWC providers are expected to bill their usual and customary rate.

ii. Reimbursement shall be at the provider billed amount or at the BWC fee, whichever is lower.

iii. Inquiries about unresolved billing issues should be directed to BWC’s Provider Contact Center at 1-800-644-6292.

iv. Bills must be submitted on BWC’s C-19 Service Invoice. The provider of interpreter services may obtain a C-19 from the BWC staff who requested these services

v. All Interpreter Services (BWC or IC) must be billed with the appropriate code(s) listed below on a C-19. a) W1930 - Interpreter Services, per fifteen (15) minutes. b) W1931 Interpreter Wait Time, per six (6) minutes, Maximum of 30

minutes per date of service (including waiting for an injured worker that does not show up for appointment).

c) W1932 - Interpreter Travel Time, per six (6) minutes (including travel time for an injured worker that does not show up for appointment).

d) W1933 - Interpreter Mileage, per mile. c. Enrollment Of Providers Of Interpreter Services

i. The provider delivering Interpreter Services for BWC and IC approved services shall be enrolled as provider type 99 (other).

ii. When an MCO requests enrollment of the interpreter, the MCO must include the vocational rehabilitation plan approved by the BWC Disability Management Coordinator with a non-certified enrollment form.

iii. The provider of Interpreter Services may enroll using the Application for Provider Enrollment and Certification (Medco-13A) form found on the Web site at https://www.bwc.ohio.gov/bwccommon/forms/BWCForms/nlbwc/ProviderForms.asp.

H. Catastrophic Case Management Plan (Previously Called Life Care Plan)

1. The Health Partnership Program places emphasis on a consistent, cooperative approach to catastrophic case management by the MCO and BWC. Each catastrophic claim is different, which necessitates highly individualized management. The Catastrophic Case Management Plan shall be considered and reviewed, with the BWC Catastrophic Nurse Advocate, for appropriateness on catastrophic claims that are chronic and result in a disabling condition greater than one (1) year. A Catastrophic Case Management Plan is not appropriate for injured worker s residing in assisted living facilities, nursing homes or Brain Injury Rehabilitation facilities as there is usually a plan of care developed by the facility. Catastrophic Case Management Plans are to be used as tools to assist in the ongoing medical management of a catastrophic injury.

https://www.bwc.ohio.gov/provider/services/agreement.asp






https://www.bwc.ohio.gov/bwccommon/forms/BWCForms/nlbwc/ProviderForms.asp

https://www.bwc.ohio.gov/bwccommon/forms/BWCForms/nlbwc/ProviderForms.asp



2. A Catastrophic Case Management Plan, which is distinct from the legally required plan of care, is to address the long-term needs of severely disabled injured workers. It is necessary to consider the needs of injured workers’ family members; however, family members are not part of the workers’ compensation claim. The MCO Catastrophic Case Manager and/or the BWC Catastrophic Nurse Advocate should staff family members’ concerns and may discuss them with the employer to see if the employer is willing to pay for crisis intervention.

3. The MCO’s Catastrophic Case Manager and the assigned BWC Catastrophic Nurse Advocate determine the necessity for a Catastrophic Case Management Plan. All conditions allowed in the claim shall be addressed on the Catastrophic Case Management Plan and must contain the current status of the allowed condition or must indicate that the allowed condition has completely resolved as of a certain date.

4. The Catastrophic Case Management Plan must be completed within sixty (60) days of referral from the MCO to the provider. The Catastrophic Case Management Plan shall include at the beginning of the report that all services in the plan are subject to BWC and MCO policy and based upon medical necessity. The provider writing the Catastrophic Case Management Plan shall work with the BWC Catastrophic Nurse Advocate and the MCO and be familiar with the unique differences required for providing a Catastrophic Case Management Plan. All Catastrophic Case Management Plans must be reviewed with the BWC Catastrophic Nurse Advocate before they are discussed with the injured worker or the injured worker’s family and before implementation.

5. The Catastrophic Case Management Plan is part of the cost of the claim and is charged to the employer’s risk (i.e., the employer’s experience), not to the Surplus Fund. The Catastrophic Case Management Plan must be billed using BWC local level code Z1000 at one-hundred ($100.00) dollars per hour, not to exceed four-thousand ($4,000.00) dollars. The Catastrophic Case Management Plan shall be billed one (1) time only, using the completion date as the date of service.

6. For a provider to provide Catastrophic Case Management Plan services the provider must possess at least one (1) of the following credentials and shall be enrolled as a provider type 76: a. Certified Occupational Health Nurse; b. Certified Rehabilitation Counselor; c. Certified Insurance Rehabilitation Specialist; d. Certified Vocational Evaluator; e. Certified Rehabilitation Registered Nurse; f. Certified Case Manager; and/or g. Certified Disability Management Specialist. or h. These credentials alone do not automatically qualify a provider to complete a

Catastrophic Case Management Plan. The MCO shall be responsible for choosing a BWC certified provider that is a certified Life Care Planner or has experience developing quality Life Care Planner s. The MCO should discuss with the provider the details of the Catastrophic Case Management Plan, as found in the MCO Policy Reference Guide, prior to the start of the plan.

XIV. EXPOSURE OR CONTACT WITH BLOOD OR OTHER POTENTIALLY INFECTIOUS MATERIALS WITH OR WITHOUT PHYSICAL INJURY

A. Exposure Claim Processing



1. BWC generally does not allow a claim for exposure/contact with blood or other potentially infection materials because an accompanying physical injury or occupational disease has not occurred.

2. In cases where there is physical injury evidence or if a worker contracts a disease after exposure and compensability is established, medical costs may be reimbursed. In certain vocations there are exceptions made in the law to pay costs of post-exposure medical diagnostic services.

B. “Exposure to Blood or Other Potentially Infectious Materials” Policy & Procedures - The

“Exposure to Blood or Other Potentially Infectious Materials”(click here) policy and procedures provide details of these scenarios and are located on our website policy section at https://www.bwc.ohio.gov/basics/PolicyLibrary/FileShell.aspx?file=%2fMedical+Policy%2fExposure+(including+SB223).htm.

XV. CHRONIC PAIN

A. Requirements - Requirements for chronic pain programs to obtain BWC certification are in OAC 4123-6-02.2(C)(13). Chronic pain programs must include all of the following overall objectives: 1. Improve general physical conditioning in order to achieve return to work readiness, if

appropriate; 2. Improve overall function for return to work readiness, if appropriate; 3. Increase comfort/decrease pain rating by use of pain management skills; 4. Decrease dependency on the health care system; 5. Identify/clarify vocational goals; if appropriate; and 6. Eliminate inappropriate use of narcotics and other medications that may cause

dependence or addiction.

B. Chronic Pain Management Treatment Program Consideration - In order to be considered for a chronic pain management treatment program, the injured worker must receive authorization for and must undergo a comprehensive multidisciplinary evaluation that includes: 1. Medical history and physical/neuromuscular examination to include review of

medications; 2. Review of past, pertinent medical records; 3. Psychological evaluation; 4. Physical therapy evaluation; 5. Occupational therapy evaluation; 6. Cardiac stress test, if necessary; and 7. Specialist consultation(s) as necessary.

C. Injured Worker Eligibility - Injured worker eligibility indicators include:

1. The injured worker is symptomatic of excessive pain behaviors disproportionate to the compensable injury or condition.

2. The injured worker has not responded to traditional medical treatment or to an extended course of individual therapy modalities. If an injured worker has not responded to traditional medical treatment or to an extended course of individual

https://www.bwc.ohio.gov/basics/PolicyLibrary/FileShell.aspx?file=%2fClaims+Policy%2fExposure+to+Blood+or+Other+Potentially+Infectious+Materials.htm

https://www.bwc.ohio.gov/basics/PolicyLibrary/FileShell.aspx?file=%2fMedical+Policy%2fExposure+(including+SB223).htm

https://www.bwc.ohio.gov/basics/PolicyLibrary/FileShell.aspx?file=%2fMedical+Policy%2fExposure+(including+SB223).htm




therapy modalities, it is recommended that the injured worker be referred to a BWC certified multidisciplinary pain management program for evaluation to determine appropriateness for entrance into the program. The ideal period for referral is six (6) months to three (3) years post injury, but referrals should not be limited to those time frames.

3. The injured worker's use/abuse of alcohol or drugs is not so excessive that it is likely to interfere with full participation in the program.

4. The injured worker is not currently experiencing any acute medical problems, is not anticipating any medical or surgical intervention and is considered medically stable to participate in a multidisciplinary, physically challenging program.

5. The injured worker has previously completed no more than one (1) multidisciplinary pain management program.

6. The injured worker is demonstrating significant emotional distress as a result of the allowed injury, such as depression, anxiety or impaired interpersonal, familial, occupational or social functioning; however, psychological dysfunction is not so severe as to interfere with full program participation.

7. The injured worker has expressed interest and desire to participate in a chronic pain management program with a goal of returning to work, if appropriate. If no return to work goal exists, there must be an expectation of documentable cost savings through decreased reliance on health care resources as a result of participation in the program.

D. Inpatient Programs - Inpatient programs are appropriate only when the injured worker's

condition is such that a highly supervised and monitored program is essential for success. One (1) or more of the following criteria must be met in order for an inpatient program to be approved: 1. The injured worker requires weaning from prescribed medication before any possible

benefit of the pain management program can be realized. 2. The injured worker exhibits personality/behaviors such that effective participation

would be unlikely in an unsupervised/unmonitored setting. 3. The injured worker needs a structured environment for psychological support and/or

medical monitoring. 4. The injured worker's pain behavior is reinforced in the home to the point that it is

necessary for the injured worker to be removed from the home in order to effectively succeed in a pain program.

E. Outpatient Programs - Outpatient programs are appropriate when the injured worker's

condition does not warrant the highly supervised environment of an inpatient program. 1. Outpatient with lodging may be warranted if the injured worker resides more than

twenty-five (25) miles from the chronic pain program facility or the injured worker is involved in dysfunctional home, family or relationship that contributes to and exacerbates pain behaviors.

2. Outpatient without lodging is appropriate if the injured worker resides within twenty-five (25) miles or less of the pain program facility, has a supportive home/family structure, does not significantly rely on medication, and does not use illicit drugs or misuse alcohol.



F. Services Provided By Chronic Pain Program - Services provided by a chronic pain program must be billed with the appropriate per diem code with the exception of the following services that may be billed separately: 1. Physician services; 2. Psychologist services; and 3. Physical therapy or occupational therapy services not included in the scheduled pain management program

G. Services Billed Separately - For services billed separately, from the chronic pain program, the 11-digit BWC provider number or National Provider Identifier of the individual treating practitioner, must be included on the CMS-1500; and the 11-digit BWC provider number or National Provider Identifier of the group practice or facility to whom the payment is to be made must be entered on CMS-1500. See Chapter 4 for detailed billing instructions.

H. Chronic Pain Program Per Diem Codes - Chronic pain program per diem codes include: 1. W1000 – Commission on Accreditation of Rehabilitation Facilities accredited or BWC

certified chronic pain program, per day; 2. W1001 - Commission on Accreditation of Rehabilitation Facilities accredited or BWC

certified chronic pain program pre-admission evaluation; and 3. W1002 - Commission on Accreditation of Rehabilitation Facilities accredited or BWC

certified chronic pain program, per half day (four (4) hours or less).

I. Contractual Agreement - The following BWC local level procedure codes are used when the chronic pain program (i.e., billing facility) has a contractual agreement with other facilities to provide travel, meals, and or lodging to the injured worker: 1. Z0600 - Vocational rehabilitation or chronic pain program, not injured worker

reimbursement, travel; 2. Z0601 - Vocational rehabilitation or chronic pain program, not injured worker

reimbursement, meals; and 3. Z0602 - Vocational rehabilitation or chronic pain program, not injured woker

reimbursement, lodging.

J. CMS-1500 - For chronic pain program per diem billing and billing the BWC local level codes to provide travel, meals and or lodging in a chronic pain program, the 11-digit BWC provider number or National Provider Identifier of the group practice or facility to whom the payment is to be made must be included on the CMS-1500.

K. Drug Testing Policy & Procedures

1. The policy provides direction for the utilization of drug testing for injured workers, especially those who are receiving or being considered for chronic opioid therapy in the management of chronic non-cancer pain.

2. Please click here or use the following BWC Web link to view “Drug Testing” policy and procedures: https://www.bwc.ohio.gov/basics/PolicyLibrary/FileShell.aspx?file=%2fMedical+Policy%2fDrug+Testing.htm.

3. Per OAC 4123-6-07(E), BWC shall continue to deny reimbursement of drug screens performed by employers or drug screening of injured workers performed in the emergency room at the time of injury.

https://www.bwc.ohio.gov/basics/PolicyLibrary/FileShell.aspx?file=%2fMedical+Policy%2fDrug+Testing.htm






XVI. UTILIZING PRESCRIPTION MEDICATION FOR THE TREATMENT OF INTRACTABLE PAIN

A. Purpose - The purpose of this policy is to provide to Ohio physicians treating Ohio

injured workers, BWC personnel, MCO, BWC’s Disability Evaluators Panel drug file reviewers and independent medical examiners and injured workers, their employers and their respective representatives:

1. The rules for prescribing narcotic medication in the treatment of intractable pain

according to the State of Ohio Medical Board of OAC 4731-21-02; 2. The expectations of the type of medical evaluation and documentation necessary to

support and facilitate using prescription medication for the treatment of intractable pain in injured workers in the Ohio Workers’ Compensation System;

3. The key elements that may be necessary in the claim file to assist BWC personnel and physicians performing reviews to determine whether the use of prescription medications in the claim meet statutory requirements;

4. The rationale and process for BWC claims management personnel to use to obtain when necessary the information needed to support or deny the use of prescription medications for the treatment of intractable pain and to facilitate the use of prescription medication, when necessary and appropriate for treatment, to obtain necessary information when insufficient information is available in the claim file, and to deter use of prescription medications when there is lack of proof of medical necessity and appropriateness.

B. Issues Important To Ohio Workers’ Compensation - Issues important to Ohio Workers’

Compensation include: 1. Lack of strict claims management guidelines regarding criteria to support use or to

deny authorization of prescription medication in the treatment of intractable pain; 2. Concern for overuse and excessive prescribing of prescription pain medications for

some injured workers as been identified by BWC personnel, pharmacists, physicians, employers and other parties, as it impacts the well being of the injured worker, potential for inappropriate use and distribution, social implications, and financial costs to the system.

3. Variance in interpretation and application of the State of Ohio Medical Board of OAC Chapter 4731-21 by physicians performing claims management services for BWC and BWC personnel, which ultimately impacts authorization/denial decisions regarding use of prescription medications.

4. Lack of use of prescription medication, particularly opioids, by physicians who are treating chronic intractable (non-malignant, benign) pain in some of Ohio’s injured workers has been identified as a pattern as opposed to appropriate utilization.

5. Appropriate use, careful surveillance and escalating vigilance with longer-term higher doses is required.

C. Statutes - Statutes regarding the use of prescription medication for the treatment of

intractable pain have changed considerably both nationally and in Ohio. 1. The State of Ohio Medical Board has established standards and procedures for

physicians regarding the diagnosis and treatment of intractable pain. These rules are contained in OAC Chapter 4731-21.

2. The State of Ohio Medical Board of OAC 4731-21-02 pertains to “utilizing prescription drugs for the treatment of intractable pain”.




http://codes.ohio.gov/oac/4731-21








3. Since these rules provide the legal authorization and criteria for use of the prescription drugs for treatment of intractable pain, they must also be followed by physicians providing opinions for authorization of payment of such medications in claims in either file reviews or independent medical evaluations for BWC.

4. According to OAC 4731-21-01 “Definitions” of the State of Ohio Medical Board OAC rules: a. “Intractable pain” means a state of pain that is determined, after reasonable

medical efforts have been made to relieve the pain or cure its cause, to have a cause for which no treatment or cure is possible or for which none has been found. “Intractable pain” does not include pain experienced by an injured worker with a terminal condition. “Intractable pain” does not include the treatment of pain associated with a progressive disease that, in the normal course of progression, may reasonably be expected to result in a terminal condition.”

b. To comply with this definition, reasonable medical efforts should have been made to relieve the pain or cure its cause and that the pain has a cause for which no treatment or cure is possible or at least none has been found. Therefore, intractable pain is considered only after reasonable medical efforts have been made to diagnose the cause of the pain and adequate and appropriate medical treatment has been provided to treat the cause. Many medical conditions seen in a BWC injured worker could be considered “intractable pain” (e.g., but not limited to, complex regional pain syndrome I or the chronic pain frequently associated with lumbar procedures, such as, postlaminectomy syndrome). Due to wide variance of symptoms and treatment over the clinical course of a condition, not all injured workers with these allowed conditions in the claim meet the definition of “intractable pain”.

5. OAC 4731-21-02 provides the guidelines or expectations of physicians managing intractable pain with prescription drugs. OAC 4731-21-02(A) requires: a. An initial evaluation that includes complete medical, pain, alcohol and substance

abuse histories; b. Assessment of the impact of pain on physical and psychological functions; c. Review of previous diagnostic studies and previously utilized therapies; d. An assessment of coexisting illnesses, diseases or conditions; and e. An appropriate physical examination

6. The medical diagnosis must be documented that indicates the intractable pain along with the signs, symptoms, and causes of the pain. An individual treatment plan must be documented and specify the medical justification of the treatment of intractable pain with prescription drugs on a protracted basis, the intended role of prescription drug therapy within the overall plan, and other medically reasonable treatment for relief of the intractable pain that have been offered or attempted without adequate or reasonable success. The response to the treatment must be documented along with modifications to the treatment plan. OAC 4731-21-02(A)(4)(a) states that the diagnosis of intractable pain can be made only after having the injured worker “evaluated by one (1) or more other practitioners who specialize in the treatment of the anatomic area, system, or organ of the body perceived as the source of the pain.” The prescribing physician is to maintain a copy of the report of the evaluation. The evaluation is not required, if the injured worker has been evaluated and treated within a “reasonable period of time,” by one (1) or more, other practitioners who specialize in the anatomic area, system, or organ perceived to be the source of pain and the treating practitioner is satisfied that he or she can rely on the evaluation to meet the requirements of the Rule. The practitioner is required to obtain and








maintain a copy of the records or report on which he/she relied to meet the requirements of an evaluation by a specialist. The last paragraph of OAC 4731-21-02(A) requires an informed consent be present and retained in the medical record informing the injured worker of the risks and benefits of receiving prescription drug therapy and of available treatment alternatives.

7. OAC 4731-21-02(B)(1) requires that the practitioner see the injured worker at “appropriate periodic intervals to assess the efficacy of treatment, assure that prescription drug therapy remains indicated, evaluate the injured worker’s progress toward treatment objectives, and note any adverse drug effects.” OAC 4731-21-02(B)(2) also requires ongoing assessment of functional status, the pain intensity, and its interference with activities of daily living, quality of life, and social activities. If there is evidence or behavioral indications of drug abuse, the practitioner may obtain a drug screen. According to OAC 4731-21-02(B)(3), “It is within the practitioner’s discretion to decide the nature of the screen and which type of drug(s) to be screened.” Results of the screening must be documented in the injured worker’s medical record.

8. OAC 4731-21-02(C) requires immediate consultation with an addiction medicine or substance abuse specialists if the practitioner believes or has reason to believe the injured worker is suffering from addiction or drug abuse.

9. Based on the above statutory and regulatory documents described, the use of prescription medication for the treatment of chronic intractable pain is acceptable in Ohio on a protracted basis or in amounts or combinations that may not be appropriate when treating other medical conditions so long as the treating physician complies with the State of Ohio Medical Board rules. Based on Ohio Supreme Court decision, it is also required that the authorization of payment for services be reasonably related, reasonably necessary for treatment of the allowed injury, and that the costs are medically reasonable. To support the reasonably necessary requirement, practitioners are expected to provide medical documentation to support intractable pain and the need to use prescription medication for the treatment of intractable pain when present. Medical records must also reflect or explain how the intractable pain and its treatment are reasonably related to the allowed injury in the claim.

10. Key elements expected to be present in the medical file include but are not limited to: a. Reasonable medical efforts (e.g., diagnostic study, consultation, and treatment)

have been performed to relieve the pain, identify the source, and cure its cause. b. No other treatment or cure is possible or none has been found. c. The initial evaluation by the treating practitioner meets the requirements of OAC

4731-21-02. This is not intended to be point-by-point specific, but that the medical records do document sufficient history, pain description, relatedness of the pain to the allowed condition in the claim, alcohol and substance abuse history, assessment of physical and psychological function, diagnostic studies and treatment performed, and an appropriate physical examination.

d. Appropriate consultation has been performed by either consultation or previous treating specialist, as defined by OAC 4731-21-02 within a reasonable period, not to exceed six (6) months from the beginning of such treatment.

e. Medical records provide appropriate documentation to support continued use of the medication consistent with OAC 4731-21-02. This includes adequate monitoring of the injured worker on a periodic basis to determine the continued need for prescription medication.















11. BWC expects practitioners to perform or receive authorization as part of the treatment guidelines for the following services: a. Periodic office visitation to monitor treatment compliance, results, physiologic and

psychological functioning; b. In certain claims, it may be necessary to obtain periodic urine drug testing to

determine drug abuse based on evidence or behavioral indications of addiction as described in OAC 4731-21-02(B)(3 (i.e., This most likely would be no more); frequent than quarterly);

c. In all claims receiving medications for intractable pain, checking the Ohio Automated Rx Reporting System report is advisable; and

d. Referral to an addiction medicine specialist or substance abuse specialist for consultation and evaluation (most likely each case would need to be evaluated for treatment) if the practitioner believes or has reason to believe the injured worker is suffering from addiction or drug abuse as described in OAC 4731-21-02(C).

12. Since there is no specific allowance of “chronic intractable pain”, BWC personnel involved with claim management determinations and physicians performing file reviews or independent medical evaluations for BWC should consider the following criteria in regard to the use of prescription medication to treat chronic intractable pain: a. That the medical records meet the definition of “intractable pain” as defined by

the State of Ohio Medical Board particularly in relation to reasonable medical efforts to determine the source and treat the cause of the pain have been documented;

b. That a second opinion from an appropriate specialist has been performed; c. That the medical records provide a reasonable relationship of the symptoms to

the allowed conditions in the claim; and d. That the use of such medication is reasonably necessary to help manage the

symptoms experienced by the injured worker. 13. If the above criteria are met, even though there is no allowance for chronic

intractable pain on the claim, then BWC may authorize reimbursement for prescription medication used in the treatment of chronic intractable pain.

14. In claim management, many, if not most, cases would be a continuation of or “flow-through” of treatment of a condition that is presumed to be the cause of pain and for which the injured worker has received appropriate diagnostic testing, treatment, and evaluations. Many individuals considered to have “chronic intractable pain” shall have obvious limitation of activity and difficulty controlling pain following treatment of the allowed condition. Other claims shall be more difficult to assess. There may be issues of: a. Need for additional diagnostic testing; b. Need for specialist consultation; c. Uncertainty of diagnosis or relationship to the allowed conditions in the claim; or d. Medical records do not support the apparent need for continued treatment in

which case, it can be anticipated that some employers may also request an independent medical evaluation of injured workers for the purpose of justification of ongoing treatment in many of these cases.

15. In questionable cases or those requested by the employer, an independent medical evaluation performed by a specialist is appropriate to determine issues such as:


https://www.ohiopmp.gov/Portal/Default.aspx

https://www.ohiopmp.gov/Portal/Default.aspx






a. Recommendations for any additional testing to identify the source of the pain; b. Other treatment that should be considered; c. Specialty consultation that may be beneficial; d. Provide description of the pain and impact on daily living, functioning etc.; e. Clarify relationship of symptoms (pain) to the allowed conditions or work injury; f. Determine the apparent need for continued treatment; and g. Other issues as deemed necessary.

16. In most non-catastrophic workers’ compensation cases, the presumed source of pain shall be limited to the musculoskeletal system. Appropriate independent medical evaluating specialists shall be limited to orthopedists, hand surgeons for the upper extremity, neurosurgeons, physical medicine and rehabilitation specialists, and possibly occupational medicine and pain specialists depending on the nature of the issue.

17. Treating physicians who consistently fail to provide appropriate medical records or follow the State of Ohio Medical Board rules shall be referred to Disability Evaluators Panel Central or Provider Relations along with the specific claim numbers of injured workers being treated.

18. The provider can access the complete BWC position paper including references, at the following BWC Website: https://www.bwc.ohio.gov/provider/services/medpositionpapers.asp.

XVII. SPINAL DECOMPRESSION THERAPY

A. Billing - BWC requires spinal decompression therapy be billed with the CPT code 97012 for mechanical traction and shall pay one (1) unit of service per visit, regardless of the length of time the traction is applied.

B. Decision - The decision regarding authorization of decompression therapy shall remain with the individual MCO.

C. Intent Of Decompression Therapy - Decompression therapy is intended to create

negative pressure on the spine, so that the vertebrae are elongated, pressure is taken off the roots of the nerve, and a disk herniation may be pulled back into place. Decompression therapy is generally performed using a specially designed computerized mechanical table that separates in the middle.

XVIII. SMOKING DETERRENT PROGRAMS

A. Responsibility - BWC and the MCO responsible for medically managing a claim may consider reimbursement of an MCO approved/accredited smoking cessation program with or without Food and Drug Administration approved smoking deterrent drugs when specific guidelines are met. This positive behavioral modification program would include education and counseling regarding nicotine addiction and the use of nicotine replacement products, re-lapse prevention strategies, stress management techniques and/or other appropriate services that would treat an allowed pulmonary condition or improve the allowed pulmonary condition to enable the injured worker to return to work.

B. Reimbursement Of Smoking Cessation Programs

BWC requires MCO approved/accredited smoking cessation programs to be billed with the following codes:


https://www.ohiobwc.com/provider/services/medpositionpapers.asp




1. W5000 - Monitored smoking cessation program with the Food and Drug Administration approved prescription smoking deterrent drugs. Services for smoking cessation with prescription drugs, when the allowed lung condition presents a barrier to meeting established treatment and return to work goals and when the Miller Criteria have been met.

2. W5001 - Monitored smoking cessation program without the Food and Drug Administration approved prescription smoking deterrent drugs. Services for smoking cessation, without prescription drugs when the lung condition presents a barrier to meeting established treatment and return to work goals and when the Miller Criteria have been met.

C. Non-Covered Services

1. BWC does not reimburse prescription smoking deterrent drugs outside an approved smoking cessation program, except when dispensed while the injured worker is admitted to a hospital during an approved inpatient admission or during the course of an outpatient visit in a hospital. See OAC 4123-6-07(D) BWC’s Pharmacy Benefits Manager shall not reimburse smoking deterrent drugs.

2. Smoking deterrent drugs that are not Food and Drug Administration approved shall not be reimbursed and shall not be billed to BWC or the MCO.

D. Provider Enrollment & Billing - The provider of a smoking cessation program is required

to enroll as BWC certified provider and to bill for services on the CMS-1500. The bills must then be submitted to the managing MCO for reimbursement.

E. Substance Abuse Treatment Services - BWC has ensured policies for supporting an

injured worker and the injured worker’s physician or physician of record, if the injured worker is receiving opioids covered by the BWC and wants to stop using them. BWC shall reimburse for opioid treatment programs that include medication assisted treatment, behavioral and psychological counseling and inpatient detoxification. An injured worker shall be able to gain access from an addiction treatment professional that shall be able to identify and treat your substance abuse. If necessary, BWC shall reimburse for up to eighteen (18) months as long as the injured worker follows the plan developed collaboratively with the injured worker’s physician of record, physician and/or addiction treatment professional. OAC 4123-6-21.7 allows the injured worker to relapse twice during that eighteen (18) month period. The injured worker may complete these programs without adding drug dependency as an allowed claim condition as long as the injured worker has a plan of care.








CHAPTER 2 Final - Ohio Bureau of Workers' Compensation · PDF fileAugust 2017 2-1 Workers’ Compensation System Chapter 2 ... the Health Insurance Claim Form (CMS-1500), as the...

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