DE Dept of Labor Message 9.6.13

Delaware Office of Workers’ Compensation (OWC)

Health Care Payment System (HCPS)

Please do not respond to this ListServ e-mail.  

If you have any additional questions, feel free to call (302-761-8200) or e-mail

( hcpaymentquestions@state.de.us ) the Delaware Office of Workers’ Compensation, Medical Component. 

As many of you may already know, significant workers’ compensation regulation changes go into effect on Wednesday, September 11, 2013.  Between now and then, the DOL web pages that contain the DE Workers’ Compensation HCPS will significantly change.  The web page now contains the new itemized fee schedule, fee schedule introduction and guidelines; utilization review; health care practice guidelines, the new drug formulary, the new “Justification for Use of Non-Preferred Medication” form, and a revised “Employer Modified Duty Availability Report”.  Keep in mind, DOL publishes all the past iterations of the itemized fee schedule and fee schedule introduction and guidelines, so users may still access them for treatment or services rendered prior to 9/11/13.  The provider certification and frequently asked questions pages will be published to the web on 9/9/13 or 9/10/13.  The regulation changes go into effect on 9/11/13; and until then, folks still need access to the current FAQ page (we don’t publish all the iterations of the FAQ page).  You may also notice a different look to the published certified provider list.  We will send more info regarding the list later next week.  As the changes are published to the web, you may access them at http://dowc.ingenix.com/DWC.asp.    

 

The Sept 2013, Register of Regulations newsletter contains the final regulations and is available now athttp://regulations.delaware.gov/register/september2013/final/17%20DE%20Reg%20322%2009-01-13.htm.  You will find the following technical changes from the proposed (July 2013) to the final (Sept 2013) version of the published regulations:

 

• ANESTHESIA – 19 DE Admin Code 1341, Section 4.20.1.1 – The proposed regulations omitted the complete formula needed to uniformly calculate anesthesia fees.  The final version contains the omitted pieces.
• REVENUE NEUTRAL – 19 DE Admin Code 1341, Section 4.3.3 – The proposed regulations omitted where (on the DOL’s web page) users would find any special instructions available to maintain revenue neutrality when coding changes do not calculate as a simple A + B = new fee.
• ACUPUNCTURE – 19 DE Admin Code 1342, PARTS A-F, of the Health Care Practice Guidelines – The originally proposed regulations omitted language that was included when the Lower Extremities practice guideline was added in 2011.  The final versions of all the other (PARTS A-F) health care practice guidelines (lower extremities already contains this language) now add “or a licensed acupuncturist” to the list of health care providers, who should perform acupuncture.

 

Attached are the following documents you may find helpful:

• LIST OF REG CHANGES…. – This list itemizes all the regulation changes in the fee schedule instructions and guidelines, as well as the workers’ compensation health care practice guidelines and the changes from the proposed (July 2013) to the final (Sept 2013) versions of the regulations published in the Register of Regulations newsletters.  It’s a great tool to use when you review the regulation changes.
• FAQ Page Changes….. – This lengthy document contains a complete copy of the revised frequently asked questions page, which is scheduled to be published to the DOL web page on 9/9/13 or 9/10/13.  As I mentioned earlier, folks will need the current FAQ information until 9/11/13.
• FORMS Employer…. – The revised “Employer’s Modified Duty Availability Report” now includes the carriers’ distribution responsibilities, which went into effect on 6/27/13 (when HB175 was signed into law).  While we went through this process, we appreciate that folks had to conform to the statute change from 6/27/13 until 9/11/13 using a form with outdated instructions.
• Pharmacy Formulary… – This new mandatory pharmacy formulary replaces its recommended predecessor and hones in on certain categories of drugs, particularly those that put users at risk for addiction/abuse.  You may find other categories of drugs discussed within the appropriate workers’ compensation health care practice guidelines. 19 DE Admin Code 1341, Section 4.13.8 (“the regulations”) guides the use of generic (“preferred) over brand name (“non-preferred”) drugs (see http://dowc.ingenix.com/info.asp?page=rules#413).  
• Pharmacy Justification Form… – A new form (see attached) physicians must use to justify prescribing a brand name (“non-preferred”) drug. 

 

Itemized Fee Schedule – 9/11/13 Update

 

You will notice significant changes in the Itemized Fee Schedule, effective for treatment or services provided on or after 9/11/13.

• Anesthesia codes are now omitted from the itemized fee schedule and are paid using a specific per unit charge and standardized calculation, which is embedded in 19 DE Admin Code1341, Section 4.20.1.1 (“the regulations”).  Once the statutorily mandated fee freeze ends with the January 31, 2014 update, the increased (based on the change in the consumer price index) unit charge will be published on the DOL web site in the HCPS’ frequently asked questions page (FAQ#6).  The standardized calculation will remain the same.
• HB175 and these regulation changes are reflected in the itemized fee schedule.  If you review the attached “LIST OF REG CHANGES…,” note where it says “Adds 85% of (extra 15% discount).”  Those categories of medical codes will show a 15% decrease in fees.   
• HB175 mandated the use of a formula based on CMS relative value units where insufficiently reliable data previously existed (see 19 Del. C. §2322B(3)(b) athttp://delcode.delaware.gov/title19/c023/sc02/index.shtml).  You will see a significant reduction in medical codes listed in the itemized fee schedule at POC85.  Wherever POC85 fees still exist, either 1) CMS did not have a relative value unit or 2) not enough fee data points existed to create a statistically valid conversion factor.  Both of those elements were needed to create a specific fee.

 

Special Revenue Neutral Instructions for Electromyography CPT Codes, Effective 9/11/13

In 2012, CPT codes 95885 and 95886 were added and now bundle electromyography codes (95860, 95861, 95863, 95864, and 96870) previously billed using separate fees.  Effective 9/11/13, the CPT codes 95885 and 95886 in the itemized fee schedule only reflect the fees for one (1) extremity.  The following table gives the revenue neutral fees for all the extremities.  

 

CPT Code 95885			CPT code 95886
Number of Extremities	Fee – geozip 197/198	Fee – geozip 199	Number of Extremities	Fee – geozip 197/198	Fee – geozip 199
1	$228.69	$73.20	1	$354.99	$207.64
2	$268.27	$115.55	2	$416.43	$327.78
3	$315.91	$172.88	3	$490.38	$490.38
4	$316.86	$147.95	4	$491.86	$419.67

I apologize for the lengthy e-mail, but I am trying to give you as much info as I can to tackle these voluminous changes.  Please call (302-761-8200) or e-mail hcpaymentquestion@state.de.us, if you have questions concerning this message.

Sincerely,

Donna Forrest

Medical Component Manager, Delaware Office of Workers’ Compensation

4425 N. Market St., 3rd Floor, Wilmington, DE  19802

Phone:  302-761-8200  Fax:  302-761-6601   hcpaymentquestions@state.de.us