DEPARTMENT OF ENERGY, LABOR & ECONOMIC GROWTH

                       WORKERS' COMPENSATION AGENCY

                  WORKERS' COMPENSATION HEALTH CARE SERVICES


(By authority conferred on the workers' compensation agency by  sections  205 
and 315 of 1969 PA 317, section 33 of 1969 PA 306,  Executive  Reorganization 
Order Nos. 1982-2, 1986-3, 1990-1, 1996-2, and 2003-1, MCL 418.205,  418.315, 
24.233, 18.24, 418.1, 418.2, 445.2001, and 445.2011)


                      PART 1.  GENERAL PROVISIONS

R 418.10101   Scope.
  Rule 101. (1) These rules do all of the following:
  (a) Establish procedures by which the employer shall furnish, or  cause  to 
be furnished, to an employee who receives a personal injury arising  out   of 
and in the course of  employment,   reasonable   medical,    surgical,    and 
hospital services and medicines, or other attendance or treatment  recognized
 by  the laws of the state as legal, when needed.  The employer  shall   also 
supply  to the injured employee  dental  services,    crutches,    artificial 
limbs,  eyes, teeth, eyeglasses,  hearing  apparatus,  and  other  appliances 
necessary to cure, so far  as  reasonably  possible,  and  relieve  from  the 
effects of the injury.
  (b) Establish schedules of maximum fees by a health facility   or    health 
care  provider  for  such  treatment  or   attendance,    service,    device, 
apparatus,  or medicine.
  (c) Establish procedures by which a health care provider shall be paid.
  (d) Provide for the identification of utilization  of  health   care    and 
health services above the usual range of utilization for    such    services, 
based  on medically accepted  standards,  and  provide  for  acquiring  by  a 
carrier  and  by the workers' compensation agency  the   necessary   records, 
medical  bills,  and other information concerning any health care  or  health 
service under review.
  (e)  Establish  a  system  for  the  evaluation  by  a   carrier   of   the 
appropriateness in terms of both the level of and the  quality   of    health 
care  and  health services  provided  to  injured  employees,   based    upon 
medically  accepted standards.
  (f) Authorize carriers to withhold payment from,   or    recover    payment 
from, health facilities or health care providers, which have  made  excessive 
charges or which have required  unjustified  treatment,  hospitalization,  or 
visits.
  (g) Provide for the review by  the  workers'  compensation  agency  of  the 
records and medical bills of any health facility or  health   care   provider 
which  have been determined by a carrier not to be in compliance   with   the 
schedule   of  charges  established  by  these  rules  or  to  be   requiring 
unjustified  treatment, hospitalization, or office visits.
  (h) Provide for the certification by the workers' compensation  agency   of 
the carrier's professional utilization review program.
  (i) Establish that when a   health   care   facility   or    health    care 
provider provides health care or health care service that is   not    usually 
associated with, is longer in duration than,  is  more  frequent   than,   or 
extends  over  a greater number of days than  that  health  care  or  service 
usually does with the diagnosis or condition for which the patient is   being 
treated,  the  health facility or health care provider may be required by the
 carrier  to  explain the necessity in writing.
  (j) Provide for the interaction of the workers' compensation  agency    and 
the department of  labor  and  economic  growth  for  the   utilization    of 
departmental procedures for the resolution of workers' compensation disputes.
  (k) Are intended for the implementation and enforcement of section 315(2) to
  (9)  of  the  act,  provide  for  the  implementation  of   the    workers' 
compensation agency's review and decision responsibility vested  in   it   by 
those  statutory provisions. The rules and definitions are  not  intended  to 
supersede or modify the   workers'   disability   compensation    act,    the 
administrative  rules  of practice of the workers'  compensation  agency,  or 
court decisions interpreting the act or the  workers'  compensation  agency's 
administrative rules.
  (2) An independent medical examination shall be exempt from  these    rules 
and may be requested  by  a  carrier  or  an   employee.    An    independent 
medical examination, (IME), shall be conducted  by  a   practitioner    other 
than  the treating practitioner.  Reimbursement for the  independent  medical 
evaluation shall be based  on   a   contractual   agreement    between    the 
provider  of  the independent medical evaluation and the party requesting the 
examination.
  (3) These rules and the  fee  schedule  shall  not  pertain    to    health 
care services  which  are  rendered  by  an  employer  to  its  employee   in
  an employer-owned and employer-operated clinic.
  (4) If a carrier and a provider have  a  contractual   agreement   designed 
to reduce the cost of workers' compensation  health  care   services    below 
what would be the aggregate amount  if  the  fee  schedule  were  applicable,
 the contractual agreement shall be exempt from  the  fee    schedule.    The 
carrier shall be required to do both of the following:
  (a) Perform technical and professional review procedures.
  (b) Provide the annual medical  payment  report  to   the    health    care 
services division of the workers' compensation agency.

  History:   1998-2000 AACS; 2005 AACS.


R 418.10102   Claim filing limitations.
  Rule 102. (1) A provider shall bill a carrier within one year of  the  date 
of service for consideration of payment.
  (2) The one year filing rule shall not apply if the  provider  bills  after 
the one year requirement under subrule (1) of this rule due to litigation  or 
subrogation.

  History:  1998-2000 AACS.


R 418.10103   Complaints.
  Rule 103. Any person who is affected by  these   rules   may    submit    a 
written complaint to the workers' compensation agency regarding the   actions 
of  any other person who is affected by these rules.

  History: 1998-2000 AACS; 2005 AACS.


R 418.10104  Reimbursement  to  injured  worker  or  to  health  insurer  for 
compensable medical services.
  Rule 104. (1) Notwithstanding any other  provision  of  these   rules,   if 
an injured worker has paid for a health care service  and  at  a  later  date
 a carrier is determined to be responsible for  the   payment,    then    the 
injured worker shall be fully reimbursed by the carrier.
  (2) The injured worker may submit the  request  for  reimbursement   on   a 
medical or dental claim form, but shall supply to the carrier a copy  of    a 
statement including the provider name, the date of service, the procedure and 
diagnosis and documentation of the amount paid.
  (3) When a health insurer pays for a  medical   service   to    treat    an 
injured worker and subsequently  requests  reimbursement  from  the  workers' 
compensation carrier, the health  insurer  is  not  required  to  submit  the 
request  on  a  CMS 1500, or a UB-04 claim  form,  or  other    medical    or 
dental  claim  form.  The health insurer  shall  supply  to   the    workers' 
compensation  carrier,  or  the carrier's designee, a  claim  detail  showing 
the date of  service,  the  amount billed and paid, the  procedure  code  and 
diagnosis for the rendered  services.
The workers' compensation carrier shall  reimburse  the  health  insurer  the 
provider's usual and customary fee or the maximum allowable fee, whichever is 
less, for the compensable medical services in accordance with these  rules.
If the health insurer reimbursed the provider less than the amount allowed by 
these rules, then the  workers'  compensation  carrier  shall  reimburse  the 
amount paid by the health insurer.

  History: 1998-2000 AACS; 2003 AACS; 2005 AACS; 2008 AACS.



R 418.10105   Balance billing amounts in excess of fees.
  Rule 105.  The provider shall not bill the injured worker for  any   amount 
for health care services, or for late  fees  incurred,  provided   for    the 
treatment of a covered injury or illness when the amount is    disputed    by 
the  carrier pursuant to its utilization review program or when  the   amount 
exceeds  the maximum allowable payment established by these rules.

  History: 1998-2000 AACS; 2003 AACS.


R 418.10106    Procedure  codes;  relative   value   units;   other   billing 
information.
  Rule 106. (1) Upon annual  promulgation  of  R  418.10107,    the    health 
care services division of the workers' compensation agency shall  publish   a 
manual separate from these rules containing all of the following information:
  (a) All CPT® procedure codes used for billing health care services.
  (b) Medicine,  surgery,  and  radiology  procedures  and  their  associated 
relative value units.
  (c) Hospital maximum payment ratios.
  (d) Billing forms and instruction for completion.
  (2) The procedure codes and standard  billing  and   coding    instructions 
for medicine, surgery, and radiology services shall  be  adopted   from   the 
most  recent  publication   entitled    "Physicians'    Current    Procedural 
Terminology, (CPT®)" as adopted by reference in R 418.10107. However, billing
 and  coding guidelines published in  "Physicians'    Current    Terminology, 
(CPT®)"  do  not guarantee reimbursement. A carrier shall   only    reimburse 
medical  procedures for a work-related injury or illness that are  reasonable 
and  necessary  and are consistent with accepted medical standards.
  (3) The formula and methodology for  determining   the    relative    value 
units shall be adopted from  the   "Medicare   RBRVS   Fee    Schedule"    as 
adopted  by reference in R 418.10107 using  geographical   information    for 
Michigan.   The geographical information, (GPCI), for these rules is a melded
 average  using 60% of the figures  published  for  Detroit  added   to   40% 
of  the  figures published for the rest of the state.
  (4) The  maximum   allowable   payment   for   medicine,    surgery,    and 
radiology services shall be determined by multiplying the relative value unit
 assigned to the procedure times the conversion  factor   listed    in    the 
reimbursement section, part 10 of these rules.
  (5) Procedure codes from  "Medicare's  National  Level  II   Codes   HCPCS" 
as adopted by reference in 418.10107 shall  be  used  to  describe   all   of 
the following services:
  (a) Ambulance services.
  (b) Medical and surgical expendable supplies.
  (c) Dental procedures.
  (d) Durable medical equipment.
  (e) Vision and hearing services.
  (f) Home health services.
  (6) Both of the following medical  services  shall  be    considered    "By 
Report" (BR):
  (a) All ancillary services listed in  "Medicare's   National    Level    II 
CODES HCPCS", referenced in R 418.10106.
  (b) All CPT® procedure codes that do not have an assigned relative value.

  History: 1998-2000 AACS; 2003 AACS; 2004 AACS.


R 418.10107   Source documents; adoption by reference.
  Rule 107. The following documents are adopted by reference in  these  rules 
and are available  for  inspection  at,  or  purchase  from,  the  workers'   
compensation agency, health care  services  division,   P.O.   Box   30016,   
Lansing,  Michigan 48909, at the cost listed or from the organizations listed:
  (a)  "Physicians'  Current  Procedural   Terminology    (CPT®)    2009,"    
professional edition,  copyright   October   2008,   published   by    the    
American   Medical Association, PO Box 930884,  Atlanta   GA,   31193-0884,   
order  #  EP888809DJR, 1-800-621-8335. The publication may be purchased at  a 
cost of  $102.95,  plus shipping and handling as of the time of  adoption  of 
these rules.   Permission to use this publication is on file in the  workers' 
compensation agency.
  (b) "Medicare's National  Level  II  Codes,   HCPCS,   2009,"   copyright   
December 2008, published by the American Medical Association, P.O. Box 930884 
 Atlanta  GA   31193-0884,  order   #   OP095109DJR,   customer    service    
1-800-621-8335.   The publication may be purchased at a cost of $94.95, plus  
$11.95  for  shipping and handling as of the time of adoption of these rules.
  (c) "Medicare RBRVS 2008:  The  Physicians'  Guide,"  published  by   The   
American  Medical   Association,   P.O.   Box   930876,    Atlanta    GA      
31193-0876,    order  #OP059608,  1-800-621-8335.   The  publication  may  be 
purchased  at  a  cost  of $89.95, plus $11.95 shipping and  handling  as  of 
the time of adoption of these rules.
  (d) "Medicare RBRVS 2009: The Physicians' Guide," published by The American 
Medical  Association,  P.O.  Box  930884,  Atlanta  GA    31193-0884,   order 
#OP059609DJR, 1-800-621-8335.  The publication may be purchased at a cost  of 
$91.95, plus $11.95 shipping and handling as of the time of adoption of these 
rules.
  (e) "International Classification of Diseases, ICD-9-CM 2009 Volumes 1  &   
2," copyright September 2009, American  Medical   Association,   P.O.   Box   
930884, Atlanta GA  31193-0884, order  #OP065109DJR,  1-800-621-8335.   The   
publication may be purchased at a cost of $92.95, plus  $11.95  shipping  and 
handling as of the time of adoption of these rules.
  (f) "2009 Drug Topics Red Book," published by Thomson Healthcare DMS  Inc, 
PO Box 2244, 82 Winter Sport Lane, Williston, VT   05495,  1-800-678-5689.    
The publication may be purchased at a cost of  $76.95,  plus   $12.95   for   
shipping and handling as of the time of adoption of these rules.
  (g) "Official UB-04 Data Specifications Manual  2009  (v.  3.00),  July  1, 
2008," developed in cooperation with the American  Hospital   Association's   
National Uniform  Billing  committee,  published   by   American   Hospital   
Association, National Uniform Billing Committee -  UB-04,  P.O.  Box  92247,  
Chicago,  IL 60675-2247, 1-312-422-3390.  As of the time of adoption of these 
 rules,  the cost of the publication is $150.00.

  History: 1998-2000 AACS; 2001 AACS; 2002 AACS; 2003 AACS; 2004  AACS;  2005 
AACS; 2006 AACS; 2006 AACS; 2007 AACS; 2008 AACS; 2009 MR 12,  Eff.  July  7, 
2009.

Editor's Note: An obvious error in R 418.10107(f)  was  corrected   at    the 
request of the promulgating agency, pursuant to Section 56 of 1969 PA 306, as 
amended by 2000 PA 262, MCL 24.256.  The  rule  containing  the   error   was 
published  in Michigan Register, 2009 MR 12.  The memorandum  requesting   the 
correction  was published in Michigan Register, 2009 MR 13. 



R 418.10108   Definitions; A to I.
  Rule 108. As used in these rules:
  (a) "Act" means 1969 PA 317, MCL 418.101 et seq.
  (b) "Adjust" means that a carrier or a carrier's agent reduces   a   health 
care provider's request for payment to  the  maximum  fee  allowed  by  these 
rules,  to a provider's usual and customary charge, or,  when   the   maximum 
fee  is  by report, to a reasonable amount. Adjust also means when a  carrier 
re-codes  a procedure, or reduces payment as a result of professional review.
  (c) "Agency" means the workers' compensation  agency  in   the   department 
of labor & economic growth.
  (d) "Appropriate care"  means  health  care  that  is  suitable    for    a 
particular person, condition, occasion, or place.
  (e) "BR" or "by report" means that  the  procedure  is  not   assigned    a 
relative  value  unit,  (RVU)  or  a  maximum  fee  and  requires  a  written 
description.
  (f) "Carrier" means an  organization  which  transacts  the   business   of 
workers' compensation insurance in Michigan and  which  may  be  any  of  the 
following:
  (i) A private insurer.
  (ii) A self-insurer.
  (iii) One of the funds of chapter 5 of the act.
  (g) "Case" means a covered injury or illness which occurs on   a   specific 
date and which is identified by the worker's  name  and  date  of  injury  or 
illness.
  (h) "Case record"  means  the  complete  health  care  record   which    is 
maintained by a carrier and which pertains to a  covered  injury  or  illness 
that occurs on a specific date.
  (i) "Complete procedure" means a procedure that contains  a    series    of 
steps that are not to be billed separately.
  (j) "Covered injury  or  illness"  means  an  injury   or    illness    for 
which treatment is mandated by section 315 of the act.
  (k)  "Current  procedural  terminology",  (CPT)"  means   a   listing    of 
descriptive  terms  and  identifying   codes   and   provides    a    uniform 
nationally  accepted nomenclature  for  reporting   medical   services    and 
procedures.   "Current procedural  terminology"  provides  instructions  for
 coding   and   claims processing.
  (l) "Dispute" means a disagreement between a carrier or a  carrier's  agent 
and a health care provider on the application of these rules.
  (m) "Durable  medical  equipment"  means  specialized  equipment  which  is 
designed to stand repeated use, which is used to serve a medical purpose, and 
which is appropriate for home use.
  (n) "Emergency condition" means that a delay in treating  a  patient  would 
lead to a significant increase in the threat to the patient's life or  to   a 
body part.
  (o)  "Established  patient"  means  a  patient    whose     medical     and 
administrative records for a particular covered injury   or    illness    are 
available  to  the provider.
  (p) "Expendable medical supply" means a disposable article that  is  needed 
in quantity on a daily or monthly basis.
  (q) "Facility" means an entity licensed by the state in accord  with   1978 
PA 368, MCL 333.1101 et seq. The office of an  individual   practitioner   is 
not considered a facility.
  (r) "Focused review" means the evaluation  of  a  specific   health    care 
service or provider to establish patterns of use and dollar expenditures.
  (s) "Follow-up days" means  the  days  of  care  following    a    surgical 
procedure that are included in the procedure's maximum allowable payment, but 
does  not include care for complications.  If the surgical  procedure   lists 
"xxx"  for the follow-up days, then the global concept does  not  apply.   If
 "yyy"  is listed for follow-up days, then the carrier shall set  the  global 
period.  If "zzz" is used, then the procedure code is part of another service
 and  falls within the global period of the other service.
  (t)  "Health  care  organization"  means  a  group  of   practitioners   or 
individuals joined together to provide health care  services   and   includes 
any  of  the following:
  (i) Health maintenance organization.
  (ii) Industrial or other clinic.
  (iii) Occupational health care center.
  (iv) Home health agency.
  (v) Visiting nurse association.
  (vi) Laboratory.
  (vii) Medical supply company.
  (viii) Community mental health board.
  (u) "Health care review" means the review of a health care case  or   bill, 
or both,  by  a  carrier,  and  includes  technical   health   care    review 
and professional health care review.
  (v) "Incidental surgery" means a surgery which is performed   through   the 
same incision, on the same day, by the  same  doctor  of   dental    surgery, 
doctor  of medicine, doctor of osteopathy, or  doctor   of    podiatry    and 
which  is  not related to diagnosis.
  (w)  "Independent  medical  examination"  means    an    examination    and 
evaluation which is requested by a carrier or  an  employee  and   which   is 
conducted  by  a different practitioner than the  practitioner  who  provides 
care.
  (x) "Independent procedure" means a procedure that  may  be   carried   out 
by itself, separate and apart from the total service that usually accompanies 
it.
  (y) "Industrial medicine clinic" also referred  to  as   an   "occupational 
health clinic" means  an  organization  that   primarily    treats    injured 
workers.  The industrial medicine clinic or  occupational  clinic  may  be  a
 health  care organization as defined by these rules or may be a clinic owned 
and  operated by a hospital for the purposes of treating injured workers.
  (z)  "Insured  employer"  means  an  employer   who   purchases    workers' 
compensation insurance from an insurance company that is licensed  to   write 
insurance  in the state of Michigan.

  History: 2000 AACS; 2001 AACS; 2003 AACS; 2005 AACS.


R 418.10109  Definitions; M to U.
  Rule 109. As used in these rules:
  (a) "Maximum allowable payment" means the maximum fee for a procedure  that 
is established by these rules,  a  reasonable  amount  for  a  "by  report"   
procedure, or a provider's usual and customary charge, whichever is less.
  (b) "Medical only case"  means  a  case  that  does  not   involve   wage   
loss compensation.
  (c)  "Medical  rehabilitation"  means,  to   the   extent   possible,   the 
interruption, control, correction, or amelioration of a medical or a physical 
problem  that causes incapacity through the use of  appropriate   treatment   
disciplines  and modalities that are  designed  to  achieve   the   highest   
possible  level  of post-injury function and a return to gainful employment.
  (d) "Medically accepted  standards"  means  a  measure  which  is  set  by  
a competent authority as the rule for evaluating  quantity  or  quality  of   
health care or health care services ensuring that the health care is suitable 
for  a particular person, condition, occasion, or place.
  (e) "Morbidity" means the extent of illness, injury, or disability.
  (f) "Mortality" means the likelihood of death.
  (g) "New patient" means a  patient  who  is  new  to  the  provider  for  a 
particular covered injury or illness and who needs to  have   medical   and   
administrative records established.
  (h) "Nursing home" means a nursing  care  facility,  including  a  county   
medical care facility, created pursuant to the provisions of 1885 PA 152, MCL 
36.1.
  (i) "Orthotic equipment" means an orthopedic apparatus that  is  designed   
to support, align, prevent or correct  deformities  of,  or   improve   the   
function of, a movable body part.
  (j) "Pharmacy" means the place  where  the  science,  art,  and  practice   
of  preparing,   preserving,   compounding,   dispensing,   and    giving     
appropriate instruction in the use of drugs is practiced.
  (k) "Practitioner" means  an  individual  who  is  licensed,  registered,   
or certified as used in the Michigan  public  health  code,  1978  PA  368,   
MCL 333.1101.
  (l) "Primary procedure" means the  therapeutic  procedure  that  is  most   
closely related to the principal diagnosis and  has  the  highest  assigned   
relative value unit (RVU).
  (m) "Properly submitted bill" means a request by a provider  for  payment   
of health care services  which  is  submitted   to   a   carrier   on   the   
appropriate completed claim form with attachments as required by these rules.
  (n) "Prosthesis" means an artificial substitute for a missing  body  part.  
A prosthesis is constructed by a "prosthetist", a person who is skilled  in   
the construction and application of a prosthesis.
  (o)  "Provider"  means  a  facility,  health  care   organization,   or   a 
practitioner.
  (p) "Reasonable amount" means a payment based upon the  amount  generally   
paid in the state for a particular procedure code using data  available  from 
 the provider, the carrier, or  the  workers'  compensation  agency,  health  
care services division.
  (q)   "Restorative"   means   that   the   patient's   function    will     
demonstrate measurable improvement in a reasonable and generally  predictable 
 period  of time and includes appropriate periodic care to maintain the level 
of function.
  (r) "Secondary procedure" means a surgical procedure which  is  performed   
to ameliorate conditions that are found to exist during  the  performance  of 
 a primary surgery and which is considered an independent procedure that  may 
not be performed as a part  of  the  primary  surgery  or  for  the  existing 
condition.
  (s)  "Specialist"  means   any   of   the   following   entities    that    
are board-certified, board-eligible, or  otherwise  considered  an   expert   
in  a particular  field  of   health   care   by   virtue   of   education,   
training,  and experience generally accepted in that particular field:
  (i) A doctor of chiropractic.
  (ii) A doctor of dental surgery.
  (iii) A doctor of medicine.
  (iv) A doctor of optometry.
  (v) A doctor of osteopathic medicine and surgery.
  (vi) A doctor of podiatric medicine and surgery.
  (t) "Subrogation" means substituting one creditor for another.  An  example 
of subrogation in workers' compensation is when  a  case  is  determined  to  
be workers' compensation and the health benefits plan has already paid  for   
the service and is requesting the workers'  compensation  carrier  or   the   
provider to refund the money that the plan paid on behalf of the worker.
  (u)  "Technical  surgical  assist"  means  that  additional  payment  for   
an assistant  surgeon,  referenced  in  R   418.10416,   is   allowed   for   
certain designated surgical procedures. The Health Care  Services   Manual,   
published annually by the workers' compensation agency, denotes  a  surgical  
procedure allowing payment for the technical surgical assist with the  letter 
"T."
  (v) "Treatment plan" means  a  plan  of  care  for  restorative  physical   
treatment services that indicates the diagnosis and anticipated goals.
  (w) "Usual and customary charge"  means  a  particular  provider's  average 
charge for a procedure to all payment sources, and includes itemized  charges 
 which were previously billed separately and  which  are  included  in  the   
package  for that procedure as defined by these rules.  A usual and customary 
charge for a procedure shall be calculated based on data beginning January 1, 
2000.

  History: 1998-2000 AACS; 2004 AACS; 2005 AACS; 2009 MR  12,  Eff.  July  7, 
2009.


R 418.10110   Program Information.
  Rule  110.  The  workers'  compensation  agency   shall   provide   ongoing 
information regarding these rules for providers, carriers, and  employees.
The  program shall include distribution of appropriate information materials.
 The  health care services division shall  provide   periodic   informational 
sessions  for providers, billing organizations, and carriers.

  History: 1998-2000 AACS; 2005 AACS.


R 418.10111   Advisory committee.
  Rule 111. The director of the workers' compensation agency  shall   appoint 
an advisory committee from names  solicited  from  provider,   carrier,   and 
employee organizations.  The advisory committee shall include five  advocates 
for  the concerns of providers, five advocates for the concerns of employees, 
and five advocates for the  concerns  of  carriers.   The  director  of   the 
workers' compensation agency shall appoint a sixteenth member to act as chair 
without a vote.  The advisory committee shall meet not  less  than  twice  a
 year.
Additional  meetings  shall  be  scheduled  if  requested  by  the   workers' 
compensation agency, the chair, or a majority of the committee.  Members  may 
be removed by the director of the workers' compensation agency for  cause  or 
for missing more than one-half of the  meetings  in  a  year.   The  advisory 
committee shall perform general program oversight  and  assist  the  workers' 
compensation agency with the following:
  (a) Annual review of the rules and the fee schedule.
  (b) Development of   proposed   amendments   to   the   rules    and    fee 
schedule, including payment methodologies.
  (c) Review of data reports and data analyses.
  (d)  Review   health   care   service   disputes,    resulting    from    a 
carrier's professional health care review program pursuant to  these   rules, 
that  are considered by mediation, arbitration, small claims,  or  magistrate 
decisions, based on annual summary data regarding  such    disputes.     This 
summary  data shall  be  developed  by  the  agency   and    shall    include 
information   regarding  carriers  and  providers  which   accounts   for   a 
significant number of disputes.
  (e)  Review  annual  summary   data   of   complaints    made    to     the 
workers' compensation agency.

  History: 1998-2000 AACS; 2005 AACS.


R 418.10112   Missed appointment.
  Rule 112. A provider shall not receive payment  for  a  missed  appointment 
unless the appointment was arranged by the carrier or the employer.   If  the 
carrier or employer fails to cancel the appointment not less than 72 hours in 
advance and the provider is unable to arrange for  a  substitute  appointment 
for that time, then  the  provider  may  bill  the  carrier  for  the  missed 
appointment using procedure code 99199 with a maximum fee of BR.

  History: 1998-2000 AACS.


R 418.10113   Initial evaluation  and  management  service;  medical   report 
other than inpatient hospital care.
  Rule 113. (1) Except as provided in subrule (2) of this rule, and for other 
than inpatient hospital care, a provider shall furnish  the  carrier,  at  no 
additional  charge,  with  a  medical  report  for  the  initial  visit,  all 
information pertinent to the  covered  injury  or  illness  if  requested  at 
reasonable intervals, and a progress report for every 60 days  of  continuous 
treatment for the same covered injury or illness.
  (2) If the provider continues to treat an injured or ill employee  for  the 
same covered injury or illness at intervals which exceed 60  days,  then  the 
provider shall provide a progress report following each treatment that is  at 
intervals exceeding 60 days.
  (3) The medical report of the initial visit and the progress  report  shall 
include all of the following information:
  (a) Subjective complaints and objective findings, including  interpretation 
of diagnostic tests.
  (b) For the medical report of the initial visit, the history of the injury, 
and for the progress report, significant history since the last submission of 
a progress report.
  (c) The diagnosis.
  (d) As of the date of the medical report or progress report, the  projected 
treatment plan, including  the  type,  frequency,  and  estimated  length  of 
treatment.
  (e) Physical limitations.
  (f) Expected work restrictions and length of time if applicable.

  History: 1998-2000 AACS.


R 418.10114   Requests for existing medical records and reports.
  Rule 114. (1) Nothing in these rules shall preclude a carrier, a  carrier's 
agent, an  employee,  or  an  employee's  agent  from  requesting  additional 
existing medical records and reports related to a specific date of injury, in 
addition to those specified in R 418.10113,  or  those  required  for  proper 
submission of a bill from a provider.
  (2) If a provider is requested by the  carrier  to  prepare  and  submit  a 
special written report in addition to  the  medical  records  required  by  R 
418.10113, R 418.10203, R 418.10204, and R 418.10901, then the provider shall 
bill the special report using procedure code 99199-32. For special reports up 
to 3 pages in length, the carrier shall reimburse the provider at $25.00  PER 
PAGE.
  (a) Complex reports greater than 3 pages in length or record reviews  shall 
be reimbursed on a contractual basis between the carrier and the provider.

  History: 1998-2000 AACS.


R 418.10115   Responsibilities of insured employer or self-insurer.
  Rule 115. (1) An insured employer shall do all of the following:
  (a) Promptly file form 100, employer's basic report of injury,  to   report 
an injury that results in 7 or more days of  disability,  specific  loss,  or 
death, with the workers' compensation agency and its insurer.
  (b) Promptly notify its insurer of the cases that do not result in   7   or 
more days of disability, specific loss, or death.
  (c) Promptly inform the provider of the name and address of   its   insurer 
or the designated agent of the insurer to whom health care  bills  should  be 
sent.
  (d) If an insured employer receives a bill, then  the   insured    employer 
shall promptly transmit the provider's bill and documentation to the  insurer 
or the designated agent of the insurer regarding a related injury or illness.
  (2) For the purposes of this rule, a self-insurer shall  promptly    report 
all employee work-related injuries to their designated  agent,  unless   they 
are self-administered.
  (a) Unless self-administered, a self-insurer  receiving  a  bill   for    a 
medical service shall forward  the  bill  to  their  designated   agent   for 
processing  and shall inform the medical provider of the address where future 
bills shall  be sent.

  History: 1998-2000 AACS; 2002 AACS; 2005 AACS.


R 418.10116   Provider responsibilities.
  Rule 116. (1) When a licensed facility or  practitioner  licensed  in  this 
state treats an injured worker  for  a  compensable  work-related  injury  or 
illness and bills the workers' compensation carrier,  the    carrier    shall 
reimburse  the licensed  provider  or  facility   the    maximum    allowable 
payment,  or   the providers' usual and  customary  charge,   whichever    is 
less,  in  accord  with  these  rules.  A  provider  shall  do  both  of  the 
following:
  (a) Promptly bill the carrier or the carrier's  designated   agent    after 
the date of service.
  (b) Submit the bill for the medical  services  provided   to    treat    an 
injured worker on the proper claim form, to the workers' compensation carrier 
or  the carrier's designated agent and attach the documentation  required  in 
part 9 of these rules.
  (2) If the provider has not received payment within 30 days of   submitting 
a bill, then the provider shall resubmit the bill to the carrier and  add   a 
3% late fee.

  History: 1998-2000 AACS; 2002 AACS; 2003 AACS.


R 418.10117  Carrier responsibilities.
  Rule 117. (1) The carrier or its  designated  agent  shall  assure  that  a 
billing form is completed properly before  making  payment  to  the  licensed 
provider  or licensed facility.
  (2) A carrier may designate a third party to receive provider  bills   on   
its behalf.  If a carrier instructs  the  provider  to  send  the   medical   
bills directly to the third party, then the 30-day limit of this rule  begins 
 when the third party receives the bill. The  carrier  is  responsible  for   
forwarding bills and medical  documentation  when  there  is  a  third  party 
reviewing medical bills for the carrier.
  (3) A carrier or designated agent shall make payment  of  an   unadjusted   
and properly submitted bill within 30 days  of  receipt   of   a   properly   
submitted bill or shall add a self-assessed 3% late penalty to  the  maximum  
allowable payment or the provider's charge, whichever is less,  as  required  
by  these rules.
  (4) A carrier or designated agent shall record payment decisions   on   a   
form entitled "The  Carrier's  Explanation  of  Benefits"  using  a  format   
approved  by the workers' compensation  agency.  The  carrier  or  designated 
agent shall  keep a copy of the explanation of benefits and shall send a copy 
to  the  provider and to the injured worker.  The  carrier's  explanation  of 
benefits shall list a clear reason  for  the  payment  adjustment  or  amount 
disputed and  shall  notify the provider what  information  is  required  for 
additional payment.
  (5) A carrier or designated agent shall make payment of an adjusted  bill   
or portion of an adjusted bill  within  30   days   of   receipt   of   the   
properly submitted bill.  If a carrier or designated  agent  rejects  a  bill 
 in  its entirety, then the carrier or designated agent  shall  notify  the   
provider  of the rejection  within  30  days  after  receipt  of  a  properly 
submitted bill.
  (6) If a carrier requests the provider  to  send  duplicated  copies   of   
the documentation required in part 9 or  additional  medical  records   not   
required by these rules, then the carrier shall reimburse  the  provider  for 
the copying charges in accord with R 418.10118.
  (7) When the carrier has disputed a case and has not issued  a  copy   of   
the formal notice  of  dispute  to   the   medical   provider,   then   the   
carrier's explanation  of  benefits  shall  be  sent  in  response  to  the   
provider's  initial bill. The carriers' explanation of benefits shall  serve  
as  notice  to  the provider that nonpayment  of  the  bill  is  due  to  the 
dispute.

  History: 1998-2000 AACS; 2002 AACS; 2003 AACS; 2005 AACS; 2009 MR 12, Eff.
July 7, 2009.


R 418.10118    Practitioner,  facility,  and   health    care    organization 
copying charge for medical records.
  Rule 118. (1) A practitioner, facility, or health care organization  shall, 
at the request of the  carrier,  the  carrier's  agent,  the   employee,   or 
the employee's agent, furnish copies of the case record  for   a   particular 
covered injury or illness to the carrier, the carrier's agent, the  employee, 
or  the employee's agent.  The maximum fee for providing copies shall  be  45 
cents  per  page,  plus  the  actual  cost  of  mailing.   In  addition,   an 
administration charge for the staff's  time  to  retrieve  and    copy    the 
records  shall  be  paid  as follows:
0-15 minutes $2.50 Each additional 15 minute increment $2.50

The copying and handling charge shall apply to all reports and records, other 
than the original copy required pursuant to the provisions  of  R  418.10113, 
and all other reports required by these rules.  The party  who  requests  the 
records shall pay the copying charge.
  (2) The copying charge for each x-ray film requested by the   carrier    or 
the carrier's agent shall be reimbursed at $15.00,  which  includes   mailing 
and handling.
  (3) If an agent of a carrier or an employee  requests  a  copy    of    the 
case record, then the agent shall indicate the date of injury.    Only    the 
records for a specific date of  injury  covered  by  the  act    and    these 
rules  are available as specified in subrule (1) of this rule.

  History: 1998-2000 AACS; 2005 AACS.


R 418.10119   Facility medical audits.
  Rule 119. If a facility requires that a carrier conduct  an  on-site  audit 
rather than providing the medical record, then  prompt  payment  shall  occur 
within 30 days of completing the on-site audit.  If payment  does  not  occur 
within 30 days of completing the on-site audit, then the carrier shall pay  a 
3% late fee.

  History: 1998-2000 AACS.


R 418.10120   Recovery of payment.
  Rule 120. (1) Nothing in this rule shall preclude the recovery  of  payment 
for services  and  bills  which  may  later   be   found   to    have    been 
medically inappropriate or paid at an amount that is more than  the   maximum 
allowable payment.
  (2) If the carrier makes a request to the provider  for  the  recovery   of 
a payment within 1 year of the date of payment and includes a  statement   of 
the reasons for the request, then the carrier may  recover  a  payment.   The 
carrier may recover a payment made by an employee or the carrier.
  (3) Within 30 days of receipt of the carrier's request for   recovery    of 
the payment, the provider shall do either of the following:
  (a) If the provider is in agreement with the  request,  then  the  provider 
shall refund the payment to the carrier.
  (b) If the provider is not in  agreement  with  the  request,   then    the 
provider shall supply the carrier with a written detailed  statement  of  the 
reasons for its disagreement, together with a refund of  the   portion,    if 
any,  of  the payment that the provider agrees should be refunded.
  (4) If the carrier does not accept the reason for   disagreement   supplied 
by the provider, then the carrier may  file  an  application  for   mediation 
or hearing as provided for in R 418.101303 and R 418.101304.  Within 30  days 
of receipt of the provider's statement of disagreement, the  carrier    shall 
file the application  for  mediation   or   hearing   with    the    workers' 
compensation agency and the carrier shall mail a copy to the provider.
  (5) If, within 60 days of the  carrier's  request  for  recovery    of    a 
payment, the carrier does not receive either   a   full   refund    of    the 
payment  or  a statement of  disagreement,  then,  at  the  option   of   the 
carrier,  the  carrier may do either or both of the following:
  (a) File an application for mediation or hearing  and  mail  a   copy    to 
the provider.
  (b) Reduce the payable amount on  the  provider's  subsequent   bills    to 
the extent of the request for recovery of payment.
  (6) If, within 30 days of  a   final   order   of   a    magistrate,    the 
appellate commission, or the courts, a  provider  does  not  pay   in    full 
any  refund ordered, then the carrier may reduce the payable  amount  on  the
 provider's subsequent bills to the extent of the  request  for  recovery  of 
payment.

  History: 1998-2000 AACS; 2005 AACS.


R 418.10121     Rehabilitation  nurse  or  nurse   case    manager    visits; 
additional services.
  Rule 121. (1) If a carrier assigns  a  rehabilitation  nurse    or    nurse 
case manager to an injured worker's case, and the carrier requires  that  the 
nurse accompany the injured worker to  provider  visits,  then  the   carrier 
shall reimburse the provider for the additional time.
  (2) The provider may bill the  rehabilitation   nurse   or    nurse    case 
manager visit in addition to the evaluation and management service using code 
RN001.
The carrier shall reimburse the provider $25.00 for RN001.
  (3) Procedure code RN001 shall be reimbursed at the maximum  allowable  fee 
if the provider bills the procedure during  the   global   period    for    a 
surgical service.

  History:  1998-2000 AACS; 2003 AACS.



                         PART 2.  MEDICINE


R 418.10201    Medicine services; description.
  Rule 201.  Medicine  services  shall  be  described  with  procedure  codes 
90281-99199.

  History: 1998-2000 AACS.


R 418.10202   Evaluation and management services.
  Rule 202. (1) The  evaluation  and  management   procedure    codes    from 
"Current  Procedural  Terminology,  CPT®",  as  adopted  by  reference  in  R 
418.10107,  shall be used  on  the  bill   to   describe    office    visits, 
hospital  visits,   and  consultations.   These  services  are  divided  into 
subcategories of new  patient and established patient  visits.  The  services 
are also classified according  to  complexity  of  the  services.   For   the 
purposes  of  workers'  compensation,  a treating practitioner, for each  new 
case or date of injury, shall use  a   new  patient  visit  to  describe  the 
initial visit. A treating physician may not  use  procedures  99450-99456  to 
bill for services provided to  an  injured  worker.
When a practitioner applies a hot or cold  pack  during  the  course  of  the 
office visit, the carrier shall not  be  required  to  reimburse  this  as  a 
separate charge.
  (2) Minor medical and surgical supplies routinely used by the  practitioner 
or health care organization  in  the  office  visit  shall  not   be   billed 
separately.
The provider may bill separately for supplies, or other  services,  over  and 
above those usually incidental to the evaluation and management service using 
appropriate CPT® or HCPCS procedure codes.
  (3) When a specimen is obtained  and  sent  to  an   outside    laboratory, 
the provider may add 99000 to the bill to describe the handling/conveyance of 
the specimen. The carrier shall reimburse $5.00 for this service in  addition
 to the evaluation and management service.
  (4) Appropriate procedures from "Current  Procedural   Terminology,   CPT®" 
or "Medicare's Level  II  Codes,  HCPCS"  may  be  billed  in   addition   to 
the evaluation and management  service.  If  an  office  visit  is  performed 
outside of the provider's normal business hours,  the  provider   may    bill 
the  add  on procedure code, 99050,  describing  an  office  visit  performed 
after hours or on Sundays or holidays and  shall  be  reimbursed  $12.00   in 
addition  to  the evaluation and  management.   The  carrier  shall  only  be 
required  to  reimburse the miscellaneous add-on office procedures  when  the 
services  are  performed outside of the provider's normal hours of business.
  (5) A procedure that is normally part of an  examination   or    evaluation 
shall not be unbundled and billed independently.  Range  of   motion    shall 
not  be reimbursed as   a   separate   procedure   in   addition    to    the 
evaluation  and management  service  unless  the  procedure   is    medically 
necessary   and appropriate for the injured worker's condition and diagnosis.
  (6) The maximum allowable payment  for  the  evaluation   and    management 
service shall be determined by multiplying  the  relative  value  unit,  RVU, 
assigned  to the procedure code, times the conversion factor listed  in   the 
reimbursement section of these rules.
  (7) The level of  an  office  visit  or  other  outpatient  visit  for  the 
evaluation and management of a patient is not guaranteed and may change  from 
session  to session.  The  level  of  service  shall  be   consistent    with 
the  type  of presenting complaint and  supported  by  documentation  in  the 
record.
  (8) When a provider  bills  for  an  evaluation  and  management   service, 
a separate drug-administration charge  shall  not  be  reimbursed   by    the 
carrier, since this is considered a bundled service inclusive with the visit.
The drug administration charges may   be   billed   and   paid    when    the 
evaluation  and management service is not performed and billed for  a    date 
of  service.  The provider shall bill the medication separate and be paid  in
 accordance  with the reimbursement section  of  these  rules.  The  provider 
shall use the  NDC  or national drug code for the specific  drug  and  either 
99070, the unlisted  drug and supply code or the specific  J-code  listed  in
 HCPCS  to  describe  the medication administered.
  (9) When  a  provider  administers  a  vaccine  during  an  evaluation  and 
management service, both the vaccine and the administration  of  the  vaccine 
are billed as separate  services  in  addition  to   the    evaluation    and 
management  visit according to language in CPT®. Both the  administration  of 
the vaccine and the vaccine shall be  reimbursed  in  accordance   with   the 
reimbursement  provisions of these rules in addition to the visit.
  (10) Procedure code 76140, x-ray consultation,  shall  not  be   paid    to 
the provider in addition to the evaluation  and  management    service,    to 
review x-rays taken elsewhere.  The carrier shall not pay for  review  of  an 
x-ray  by a practitioner other than the  radiologist  providing  the  written 
report or the practitioner performing the complete radiology procedure.

  History: 1998-2000 AACS; 2002 AACS; 2003 AACS; 2004 AACS; 2007 AACS.


R 418.10203    Office visit or other  outpatient  visit  for  evaluation  and 
management of patient in conjunction with  ongoing  osteopathic  manipulative 
treatment or chiropractic manipulative treatment.
  Rule 203. (1) The carrier shall reimburse for the  initial  evaluation  and 
management examination billed by the provider before initiating  chiropractic 
or osteopathic manipulation. The carrier shall also reimburse for osteopathic 
manipulative  treatment  or  chiropractic  manipulative  treatment   if   the 
treatment is initiated on the same date of service.
  (2)  All  of  the  following  provisions  apply  to   ongoing   osteopathic 
manipulative treatment:
  (a)   Osteopathic   manipulative   treatment   procedure   codes    include 
pre-manipulative patient evaluation.   The  physician  may  bill  a  separate 
evaluation and management service using modifier code -25.  The carrier shall 
only reimburse the service if the documentation provided supports significant 
change of signs and symptoms  or  the  evaluation  of  another  work  related 
problem not included in the procedure or service that required the encounter.
 The physician shall document the rationale for the significant other service 
in the record.
  (b) Osteopathic manipulations  are  to  be  billed  using  procedure  codes 
98925-98929.
  (3)  All  of  the  following  provisions  apply  to  ongoing   chiropractic 
manipulative treatment:
  (a)   The   chiropractic   manipulative   treatment   codes    include    a 
pre-manipulation patient evaluation.  The  provider  may  report  a  separate 
evaluation and management service using modifier -25 to designate a  separate 
identifiable  service.   The  carrier  shall  reimburse  the  evaluation  and 
management service only when the provider  documents  significant  change  of 
signs and symptoms or the evaluation of  another  work  related  problem  not 
included in the procedure  or  service  that  required  the  encounter.   The 
provider shall document the rationale for the significant  other  service  in 
the record.
  (b) The carrier shall reimburse chiropractic  manipulative  treatment  when 
the provider bills the service with procedure codes 98940-98942.
  (4) If either a doctor of osteopathy or a doctor of chiropractic,  conducts 
a periodic re-evaluation, then a report of the evaluation shall accompany the 
bill.  A periodic re-evaluation report shall include  all  of  the  following 
information:
  (a) A description of the evaluation of function in measurable  terms  based 
on physical findings and problem identification.
  (b) A goal statement.
  (c) A treatment plan.
  (d) Physical and  functional  improvement  in  measurable  terms  that  has 
occurred in relationship  to  the  diagnosis  for  which  the  treatment  was 
prescribed.
  (e) The likelihood of continued improvement if treatment is continued.

  History: 1998-2000 AACS.


R 418.10204     Office  visit  or  other  outpatient  visit;  evaluation  and 
management of patient's progress in physical treatment.
  Rule 204. (1) An office visit or other outpatient visit for the  evaluation 
and management of a patient's progress in physical treatment  shall  only  be 
billed when there is a change of signs or symptoms and when the referring  or 
treating practitioner  provides  supporting  documentation  as  described  in 
subrule (2) of this rule.  The supporting documentation shall  indicate  that 
it is medically appropriate for the practitioner to make the evaluation.
  (2) Documentation shall include the referring  or  treating  practitioner's 
statement that an office visit  was  medically  necessary.   In  addition,  a 
report shall state that an examination was conducted and shall set forth  the 
specific findings by the practitioner, including all of the following:
  (a) A description of the evaluation of function in measurable  terms  based 
on physical findings and problem identification.
  (b) A goal statement.
  (c) A treatment plan.
  (d) Physical and  functional  improvement  in  measurable  terms  that  has 
occurred in  relationship  to  the  diagnosis  for  which  physical  medicine 
treatment was prescribed.
  (e) The likelihood of continued improvement if physical medicine  treatment 
were continued.
  (3) The report required pursuant to subrule (2) of this rule may be used to 
meet the reporting requirements of physical  medicine  services  provided  in 
these rules.
  (4) The office visit or other  outpatient  visit  for  the  evaluation  and 
management of a patient shall include  the  evaluation  procedures  that  are 
appropriate to the diagnosis.
  (5) Nothing in this rule pertains to  office  visits  or  other  outpatient 
visits for the evaluation and management of a patient that are not related to 
physical treatment.

  History: 1998-2000 AACS.


R 418.10205    Consultation services.
  Rule 205. (1) An attending physician, carrier,  third-party  administrator, 
or the injured worker may request a consultation.  A   physician   specialist 
shall  provide  consultations  using   procedure   codes    99241-99275    to 
describe  the service.
  (2)  The  carrier  may  request  a  provider  other  than   the    treating 
practitioner to perform a confirmatory consult.  The   physician   specialist 
performing   the  confirmatory  consult  shall    bill    procedure     codes 
99271-99275,  defined  in "Physicians' Current Procedural Terminology  (CPT®) 
and shall  be  subject  to the maximum payment allowance as defined  in   the 
reimbursement  section  of these rules.
  (3) If a specialist performs diagnostic procedures or testing  in  addition 
to the consultation, then  the  specialist  shall  bill    the    appropriate 
procedure code from "Physicians' Current Procedural  Terminology   (CPT®).
The  carrier shall reimburse the testing procedures in accordance with  these 
rules.

  History: 2000 AACS; 2002 AACS.


R 418.10206    Emergency department evaluation and management visit.
  Rule 206. An emergency physician shall use emergency department  evaluation 
and management service procedure codes  to  report  an  emergency  department 
visit.

  History: 1998-2000 AACS.


R 418.10207  Mental health services.
 Rule 207. (1) A psychiatrist, only, shall use procedure codes 90805,  90807, 
90809, 90811, 90813, 90815, 90817, 90819,  90822,  90824,  90827,  and  90829 
to describe treatment of a mental  health  condition,  and   shall   not   be 
billed in conjunction with, 99201-99499, an evaluation and management service.
  (2) A psychiatrist shall use procedure codes 90801 and 90802 to describe  a 
psychiatric diagnostic interview.  A psychiatric consultation may be reported 
with procedure codes 99214-99263 and shall be limited to evaluation and  does 
not include psychiatric treatment.
  (3)  An  individual  performing  psychological  testing  shall  report  the 
services using procedure codes 96100-96117.
  (4) Mental health providers shall use the following modifiers  to  describe 
the practitioner providing the health services:
  (a) -AH, for services provided by a licensed psychologist.
  (b) -AL, for services provided by a limited licensed psychologist.
  (c) -AJ, for services provided by a certified social worker.
  (d) -LC, for services provided by a licensed professional counselor.
  (e) -CS, for services provided by a limited licensed counselor.
  (f) -MF, for services provided by a licensed marriage and family therapist.
  (g) -ML, for services provided by a limited licensed  marriage  and  family 
therapist.

  History: 2000 AACS; 2001 AACS.


R 418.10208    Vision services.
  Rule 208. (1) A medical diagnostic eye evaluation by a practitioner  is  an 
integral part of all opthalmology services.
  (2)  Intermediate  and  comprehensive  ophthalmological  services   include 
medical  diagnostic  eye  evaluation  and  services,  such   as   slit   lamp 
examination,  keratometry,  opthalmoscopy,  retinoscopy,   determination   of 
refractive state, tonometry, or motor evaluation.  These procedures shall not 
be billed in conjunction with procedure codes 92002, 92004, 92012, and 92014.
  (3) Only an ophthalmologist or a doctor of optometry  shall  use  procedure 
codes 92002, 92004, 92012, and 92014.
  (4) A doctor of optometry shall use procedure codes 92002-92287 to describe 
services.
  (5) An employer is not required to reimburse  or  cause  to  be  reimbursed 
charges for an optometric service unless that  service  is  included  in  the 
definition of practice of optometry  under  section  17401  of  the  Michigan 
Public Health Code, Act 368 of 1978, as amended, being  §  333.17401  of  the 
Michigan compiled laws, as of May 20, 1992.
  (6) Suppliers of vision and prosthetic optical  procedures  shall  use  the 
appropriate procedure code V0000-V2999 listed in Medicare's National Level II 
Codes as referenced in 418.10107 (2) to describe services provided.

  History: 1998-2000 AACS.


R 418.10209    Hearing services.
  Rule 209. (1) A provider performing  a  comprehensive  otorhinolaryngologic 
evaluation shall report the service  using  the  appropriate  evaluation  and 
management service.
  (2) A provider shall not report an otoscope, a rhinoscopy, or a tuning fork 
test in addition to a comprehensive ear evaluation or office visit.
  (3) A  provider  performing  special  otorhinolaryngologic  procedures,  in 
addition to the evaluation, shall report those services using procedure codes 
92507-92599.
  (4) An audiologist  and  a  speech  therapist  shall  use  procedure  codes 
92502-92599.  An audiologist, a speech therapist, and a  speech  and  hearing 
center shall use procedure codes 92502-92599 and procedure codes V5030- V5240 
for hearing aid services.
  (5)  Hearing  aid  suppliers  shall  use  the  appropriate  procedure  code 
V5008-V5230 listed in Medicare's National Level II  Codes  as  referenced  in 
418.10107(2) to describe services provided.

  History: 1998-2000 AACS.


R 418.10212  Physical and occupational therapy; physical medicine services.
  Rule 212. (1) For  the  purposes  of  workers'   compensation,   physical   
medicine services, procedure codes 97010-97799, shall  be  referred  to  as   
"physical treatment" when the services are  provided  by   a   practitioner   
other  than  a physical therapist or an  occupational  therapist.   Physical  
therapy   means  physical  treatment  provided  by  a  licensed   physical    
therapist.  Occupational therapy means  physical  treatment  provided  by  an 
occupational therapist.
  (2) Physical medicine services shall be restorative.   If   documentation   
does not support the restorative nature of the treatment, then the  service   
shall not be reimbursed.
  (3) Any of the following may provide physical treatment, to  the   extent   
that licensure, registration, or certification law allows:
  (a) A doctor of medicine.
  (b) A doctor of osteopathic medicine and surgery.
  (c) A doctor of dental surgery.
  (d) A doctor of chiropractic.
  (e) A doctor of podiatric medicine and surgery.
  (f) A physical therapist.
  (g) An occupational therapist.
  (4) Only a licensed physical therapist, registered occupational  therapist, 
or licensed practitioner may use procedure codes  97001-97004  to  describe   
the physical  medicine   and    rehabilitation    evaluation    services.     
Job-site evaluations may be paid to a registered occupational  therapist,  a  
licensed physical  therapist,  or  a  physician.  Job-site  evaluations  for  
workers' compensation are by  report  and  are  described   on   the   bill   
using  codes WC500-WC600.
  (5) If a practitioner performs and bills for  physical  treatment,   then   
the practitioner shall do all of the following:
  (a) Perform an initial evaluation.
  (b) Develop a treatment plan.
  (c) Modify the treatment as necessary.
  (d) Perform a discharge evaluation.
The practitioner shall provide the carrier with an initial evaluation  and  a 
progress report every 30  calendar  days  and  at  discharge.   Documentation 
requirements are the same as the requirements in R 418.10204(2).
  (6) A provider  shall  report  procedure  code  97750   to   describe   a   
functional capacity evaluation. The carrier shall reimburse a maximum  of  24 
units  or  6 hours for the initial evaluation. Not  more  than  4  additional 
units  shall  be billed for a re-evaluation occurring within 2 months.
  (7)  Physical  medicine  modalities   are   those   agents   applied   to   
produce therapeutic changes to tissue and include, but are not limited  to,   
thermal, acoustic,  light,  mechanical  or  electric  energy.   Both  of  the 
following apply:
  (a) Supervised modalities include procedure  codes  970102-97028.   These   
codes do not  require  direct  1-on-1  patient  contact  by  the  provider.   
These modalities shall be performed in conjunction   with   a   therapeutic   
procedure including manipulative services or  the  modalities  shall  not  be 
reimbursed.
  (b) Constant attendance modalities are those  procedure  codes  97032-97039 
that require direct 1-on-1 patient contact by the provider.
  (8) Therapeutic procedure codes  97110-97546  are  procedures  that  effect 
change through the application of clinical   skills   and   services   that   
attempt  to improve function.  The  physician  or  therapist   shall   have   
direct  1-on-1 patient contact.
  (9) The following provisions apply to the listed modality services:
  (a) Whirlpool shall only be reimbursed when done for debridement  or   as   
part of a restorative physical treatment program.
  (b) Procedure 97010 is  a  bundled  procedure  code  and  shall  not   be   
reimbursed separately.
  (c) Not more than 1 deep heat procedure shall be billed on the same  date   
of service for  the  same  diagnosis.    Deep   heat   procedures   include   
diathermy, microwave, ultrasound, and phonophoresis.
  (d) Phonophoresis shall be  billed  using  procedure  code   97035   with   
modifier code -22 and shall be reimbursed at the same  rate  as   procedure   
code  97035, plus $2.00 for the active ingredient used in the process.
  (e)  Iontophoresis  shall  include  the  solution,  medication,   and   the 
electrodes.
  (f) Electrical stimulation shall include the electrodes.
  (g) Procedure codes 97032, 97033, and 97035 shall  not  be  reimbursed  to  
a doctor of chiropractic.
  (h) Fluidotherapy, a dry whirlpool treatment, shall be   reported   using   
code 97022.

  History: 1998-2000 AACS; 2006 AACS; 2009 MR 12, Eff. July 7, 2009.


R 418.10213    Rescinded.

  History: 1998-2000 AACS; rescinded MR 12, Eff. July 7, 2009.


R 418.10214  Orthotic and prosthetic equipment.
  Rule 214. (1) A copy of a prescription by 1 of the following is  required   
for prosthetic and orthotic equipment:
  (a) A doctor of medicine.
  (b) A doctor of osteopathic medicine and surgery.
  (c) A doctor of chiropractic.
  (d) A doctor of podiatric medicine and surgery.
  (2) Orthotic equipment may be any of the following:
  (a) Custom-fit.
  (b) Custom-fabricated.
  (c) Non-custom supply that is prefabricated or off-the-shelf.
  (3)  A  non-custom  supply  shall  be   billed   using   procedure   code   
99070, appropriate L-codes or A4570 for a prefabricated orthosis.
  (4) An orthotist or prosthetist that is certified by the American   board   
for certification  in  orthotics  and  prosthetics,  shall  bill   orthoses   
and prostheses that are custom-fabricated, molded to the patient,  or  molded 
to   a  patient  model.   Licensed  physical  and   registered   occupational 
therapists  may bill orthoses using L-codes within their  discipline's  scope 
of practice.   In addition, a  doctor  of  podiatric  medicine  and  surgery  
may  bill  for  a custom-fabricated or custom-fit, or  molded  patient  model 
foot orthosis  using procedure codes L3000-L3649.
  (5)  If  a  registered  occupational  therapist  or   licensed   physical   
therapist constructs an extremity orthosis that is not  adequately  described 
by  another L-code, then the therapist shall bill the service using procedure 
code L3999.
The carrier shall reimburse this code as a "by report"  or  "BR"  procedure.
The provider shall include the following information with the bill:
  (a) A description of the orthosis.
  (b) The time taken to construct or modify the orthosis.
  (c) The charge for materials, if applicable.
  (6) L-code procedures shall include fitting and adjustment of the equipment.
  (7) The health  care  services  division  shall   publish   the   maximum   
allowable payments for L-code procedures in the manual separate from  these   
rules.   If an L-code procedure does not have an assigned  maximum  allowable 
payment, then the procedure shall be by report, "BR."
  (8) A provider may not bill more   than   4   dynamic   prosthetic   test   
sockets without documentation of medical  necessity.   If  the  physician's   
prescription or medical condition requires utilization of more  than  4  test 
sockets, then a report shall be included with  the  bill  that  outlines  a   
detailed  description  of  the  medical  condition  or  circumstances  that   
necessitate  each  additional test socket provided.

  History: 2000 AACS; 2004 AACS; 2009 MR 12, Eff. July 7, 2009.


                        PART 4.  SURGERY


R 418.10401   Global surgical procedure; services included.
  Rule  401.  (1)  The  surgical  procedures  in   the   Current   Procedural 
Terminology as adopted in R 418.10107 always  include  the   following   list 
of  specific services in addition to the surgical procedure.
  (a)   Local   infiltration,    metacarpal/metatarsal/digital    block    or 
topical anesthesia.
  (b) Subsequent  to  the  decision  for  surgery,  1   related    evaluation 
and management encounter on the date immediately prior to or on the date   of 
the procedure is included.  However,  when  an   initial    evaluation    and 
management encounter occurs and a decision for surgery  is  made   at    that 
encounter,  the evaluation and management service is payable   in    addition 
to  the  surgical procedure.
  (c)  Immediate  postoperative   care,   including    dictating    operative 
notes, talking with the family and other physicians.
  (d)  Writing  postoperative  surgical  orders  in  the   patient's    chart 
and dictating an operative report.
  (e) Evaluating the patient in the postanesthesia recovery area.
  (f) Typical, routine, normal  postoperative  follow-up   care,    including 
suture removal, during the global period. The global period or follow-up days
 shall be listed in the surgical section  of  the  manual  published  by  the 
agency.
  (2) Intra-operative procedures required to  perform  the  surgical  service 
shall not be billed separately.

  History: 1998-2000 AACS; 2007 AACS.

  Editor's Note: An obvious error in R  408.10401  was  corrected   at    the 
request of the promulgating agency, pursuant to Section 56 of 1969 PA 306, as 
amended by 2000 PA 262, MCL 24.256.  The  rule  containing  the   error   was 
published  in Michigan Register, 2007 MR 6.  The memorandum  requesting   the 
correction  was published in Michigan Register, 2007 MR 9.


R 418.10403    Complication, exacerbation, recurrence, or presence  of  other 
disease or injury.
  Rule 403. (1) If a complication, exacerbation, recurrence, or the  presence 
of other disease or injury exists that requires additional services, then the 
services shall be reported and identified by the appropriate procedure code.
  (2) Reimbursement shall only be made for services related to, or  resulting 
from, the covered work injury.

  History: 1998-2000 AACS.


R 418.10404   Follow-up care occurring during global service.
  Rule 404. (1) Follow-up care for a diagnostic procedure shall  refer   only 
to the days required to recover  from  the  diagnostic  procedure   and   not 
the treatment of the underlying condition.
  (2) Follow-up care for therapeutic surgical  procedures    includes    only 
that  care   which   is   usually   part   of   the   surgical   service.
Complications,  exacerbations,  recurrence,  or   the   presence   of   other 
compensable  diseases  or injuries  requiring  additional   services   should 
be   reported   with   the identification  of  appropriate  procedures.   The
 follow-up  days  for  the  surgical  procedures  are  adopted    from    the 
"Medicare  RBRVS  The  Physicians Guide," as referenced  in  R  418.10107(d).
The follow-up days for each surgical procedure are identified in the "global" 
column in the   manual   published   by  the  workers'  compensation  agency, 
separate from  these  rules.   All  of  the following  apply  to  the  global 
service provider:
  (a) If a carrier requests the surgeon to see an  injured   worker    during 
the global service  period  for  the  purpose  of  job   restrictions,    job 
adjustments, or return to work, then the visit shall not be  considered  part 
of the  global surgery package.  If the carrier requests the visit, then  the 
carrier  shall prior authorize the visit assigning an authorization  number.
 The  provider shall bill the visit using procedure 99455 and modifier   -32, 
including  the authorization number in box 23 of  the  CMS  1500  form.   The 
carrier  shall  not deny a prior authorized visit  and  shall  reimburse  the 
provider for the  prior authorized visit.  The maximum allowable payment  for 
99455-32 shall be listed in the manual published separate from these rules.
  (b) The medical record shall reflect job  adjustments,   job   restrictions 
or limitations, or return to work  date  and  the  provider   shall   include 
the medical record with the bill.
  (c) If an insured employer requests the surgeon   to   see    an    injured 
worker during the  global  surgery  period   for   the   purpose    of    job 
adjustments, restrictions, or return to  work,  then  the   employer    shall 
obtain  the  prior authorization number from the carrier for the visit.
  (3)   Hospital   follow-up   care   or   a   hospital    visit    by    the 
practitioner responsible for  the  surgery  shall  be  considered   part   of 
the  surgical follow-up days listed  for  the  procedure  and  shall  not  be
 paid  as  an independent procedure.

  History: 1998-2000 AACS; 2001 AACS; 2005 AACS; 2007 AACS.


R 418.10405    Rescinded.

  History: 1998-2000 AACS; 2002 AACS.


R 418.10406    Rescinded.

  History: 1998-2000 AACS; 2002 AACS.


R 418.10407    Rescinded.

  History: 1998-2000 AACS; 2002 AACS.


R 418.10410    Incidental surgeries.
  Rule 410. The carrier shall not pay a bill for an incidental surgery  which 
is not part of the primary procedure performed, and for  which  there  is  no 
diagnostic evidence or relationship to the covered work injury.

  History: 1998-2000 AACS.


R 418.10411    Rescinded.

  History: 1998-2000 AACS; 2002 AACS.


R 418.10415    Rescinded.

  History: 1998-2000 AACS; 2002 AACS.


R 418.10416   Assistant surgeon.
  Rule 416. (1) The carrier shall  reimburse  for  an    assistant    surgeon 
service for those surgical  procedures  designated  by  CMS    as    allowing 
additional reimbursement   for   surgical   assistant.   The    heath    care 
services   manual published separate from these rules will list the  surgical
 procedures  that allow reimbursement for assistant surgeon.
  (2) Any of the following  may  bill  assistant  surgeon   services    using 
modifier -80:
  (a) A doctor of dental surgery.
  (b) A doctor of osteopathy.
  (c) A doctor of medicine.
  (d) A doctor of podiatry.
  (3) A physician's assistant  or  an  advanced  practice  nurse    with    a 
specialty  licensure  certification  issued   by   the   state    may    bill 
assistant  surgeon services using modifier -81.

  History: 1998-2000 AACS; 2007 AACS.


R 418.10417    Ophthalmological surgical procedures.
  Rule 417. Ophthalmological surgical procedure codes for the  removal  of  a 
foreign body include topical anesthesia, fluorescein staining, and lavage.

  History: 1998-2000 AACS.


        PART 5.  RADIOLOGY, RADIATION THERAPY, AND NUCLEAR MEDICINE


R 418.10501    Rescinded.

  History: 1998-2000 AACS; 2002 AACS.


R 418.10502    Rescinded.

  History: 1998-2000 AACS; 2002 AACS.


R 418.10503    Rescinded.

  History: 1998-2000 AACS; 2002 AACS.


R 418.10504  Multiple procedure policy  for  radiology  procedures  performed 
within families or groups of contiguous body parts.
  Rule 504.  (1)  A  multiple  procedure  payment  reduction   shall    apply 
to specified radiology  procedures  when  performed   in    a    freestanding 
radiology office, a non-hospital facility, or  a  physician's    office    or 
clinic.  The primary procedure, identified by the code  with   the    highest 
relative  value, shall be paid at 100% of the maximum allowable payment.   If
 the  provider's charge is less than the maximum allowable payment, then  the 
service shall  be paid at 100% of the provider's charge.
  (2) The multiple  payment  reduction  policy  shall   also    apply    when 
multiple  radiological  diagnostic  imaging  procedures  are   performed   on 
contiguous  parts of the  body,  listed  as  family-group  procedures.   When 
multiple procedures are  performed  within  these  groups  or   families   of 
procedures,   the   25%   multiple  payment  reduction  shall  apply  to  the 
technical  component  only.  The  agency shall publish in a  manual  separate 
from these rules a table listing groups of related  codes  (families).   When 
more than 1 procedure  from  each  group  (family  of  contiguous  codes)  is 
performed on the same date of service, the  technical component for the first 
procedure within each group is paid  at   100%   of   the  maximum  allowable 
payment. Each additional procedure within the  group  shall have modifier -51 
appended and the technical component  shall   be   reduced   to  75%  of  the 
maximum allowable payment, or the provider's charge, whichever  is less.

  History: 2007 AACS; 2008 AACS.


R 418.10505   Multiple  procedure  policy  for  specific  nuclear    medicine 
procedures.
  Rule 505.  (1) The multiple procedure reduction and the use   of   modifier 
-51 shall apply to the complete  procedure,  the  technical  component,   and 
the professional component, when multiples   of   the    following    nuclear 
medicine diagnostic procedure codes are performed: 78802, 78803,  78806,  and 
78807.
  (2) When the procedures listed in subrule (1) of this rule  are   performed 
in  a  hospital   setting,   the   hospital    is    reimbursed    by     the 
cost-to-charge methodology and the multiple payment rule shall    apply    to 
the  professional component billed by the radiologist.
  (3)  When  the  services  are  performed  in  an   office,    clinic,    or 
freestanding radiology office, the reduction shall be applied to the complete 
procedure.

  History: 2007 AACS.

                                PART 7.  DENTAL

R 418.10701   Scope.
  Rule 701. (1) Dental services, related   to,   or   resulting    from,    a 
covered work-related  injury  are  covered  under  these  rules.   Incidental
 dental services are not covered.
  (2) A dental provider shall bill services on  a  standard  American  dental 
claim form. The workers' compensation agency shall  publish  a  copy  of  the 
claim form and instructions for completion separate from these rules  in  the 
health  care services manual.
  (3) Dental services shall be reimbursed at either  the   dentist's    usual 
and customary fee or reasonable fee, whichever is less.

  History: 2000 AACS; 2005 AACS.


                              PART 9.  BILLING
                      SUBPART A.  PRACTITIONER BILLING


R 418.10901  General information.
  Rule 901. (1) All health care practitioners and health care  organizations, 
as defined in these rules, shall submit charges on  the  proper  claim   form 
as specified in this rule.  Copies  of  the  claim  forms   and   instruction 
for completion for each form shall be published separate from  these    rules 
in  a manual distributed by the health  care  services  division    of    the 
workers' compensation agency. Charges shall be submitted as follows:
  (a) A practitioner shall submit charges on the CMS1500 claim form.
  (b) A doctor of dentistry shall submit charges on   a    standard    dental 
claim form approved by the American dental association.
  (c) A pharmacy, other than an inpatient hospital, shall submit  charges  on 
an invoice or a pharmacy universal claim form.
  (d) A  hospital-owned  occupational,   industrial   clinic,    or    office 
practice shall submit charges on the CMS 1500 claim form.
  (e) A hospital billing for a practitioner service shall submit charges   on 
a CMS 1500 claim form.
  (f) Ancillary service charges shall be submitted on the CMS   1500    claim 
form for durable medical  equipment  and   supplies,    L-code    procedures, 
ambulance, vision, and hearing services. Charges  for  home  health  services
 shall  be submitted on the UB-04 claim form.
  (g) A shoe supplier or wig supplier shall submit charges on an invoice.
  (2) A provider shall submit all bills to the carrier within  1   year    of 
the date of service for consideration  of  payment,  except  in   cases    of 
litigation or subrogation.
  (3) A  properly  submitted  bill  shall  include  all  of   the   following 
appropriate documentation:
  (a) A copy of the medical report for the initial visit.
  (b) An updated progress report if treatment exceeds 60 days.
  (c) A copy of the initial evaluation and a progress report every  30   days 
of  physical   treatment,   physical    or    occupational    therapy,     or 
manipulation services.
  (d) A copy of the operative  report   or   office   report    if    billing 
surgical procedure codes 10040-69990.
  (e) A copy of the anesthesia record if billing anesthesia codes 00100-01999.
  (f) A copy of the radiology  report  if   submitting   a   bill    for    a 
radiology service accompanied by modifier -26.  The  carrier    shall    only 
reimburse  the radiologist for the written report, or professional component,
 upon  receipt of a bill for the radiology procedure.
  (g) A report describing the service if submitting  a  bill  for    a    "by 
report" procedure.
  (h) A copy of the medical report if a modifier is applied  to  a  procedure 
code to explain unusual billing circumstances.

  History: 2000 AACS; 2002 AACS; 2004 AACS; 2005 AACS; 2008 AACS.



R 418.10902  Billing for injectable  medications,  other  than  vaccines  and 
toxoids, in office setting.
  Rule 902. (1) The provider shall not bill the carrier  for   administration 
of therapeutic injections  when  billing  an  evaluation    and    management 
procedure code.  If an  evaluation  and  management  procedure  code  is  not 
listed, then the appropriate medication administration procedure code may  be 
billed.
  (2) The medication  being  administered  shall  be  billed   with    either 
the unlisted  drug   and   supply   code     from     physicians'     current 
procedural terminology,  (CPT®),  or  the  specific  J-code  procedure   from 
Medicare's National Level II Codes as adopted by reference in R 418.10107.
  (3) The provider shall list  the  NDC  or  national  drug  code   for   the 
medication in box 19 of the CMS 1500.
  (4)  The  carrier  shall  reimburse  the  medication  in  accordance   with 
R 418.101003a.
  (5) If the provider  does  not  list  the  national  drug  code   for   the 
medication, the carrier shall reimburse the medication using the least costly 
NDC  listed by Redbook for that medication.

  History: 2003 AACS; 2005 AACS; 2007 AACS; 2008 AACS.


R 418.10904   Procedure codes and modifiers.
  Rule 904. (1) A health care service shall  be   billed    with    procedure 
codes adopted from "Physicians' Current Procedural Terminology  (CPT®)"    or 
"HCPCS, Medicare's National Level II Codes," as referenced in R  418.10107.
Procedure codes from  "Physicians'  Current  Procedural  Terminology  (CPT®)" 
shall  not  be included in these rules, but shall be listed in   a   separate 
manual  published by  the  workers'   compensation    agency.     Refer    to 
"Physicians'   Current Procedural Terminology (CPT®)"  for  standard  billing
 instructions,  except where otherwise  noted  in  these  rules.  A  provider 
billing  services  described with procedure codes from  "Medicare's  National 
Level II Codes" shall refer to the publication as adopted by reference  in  R 
418.10107 for coding information.
  (2) The following ancillary service  providers  shall  bill   codes    from 
"HCPCS, Medicare's National Level II Codes," as adopted by reference   in   R 
418.10107, to describe the ancillary services:
  (a) Ambulance providers.
  (b) Certified orthotists and prosthetists.
  (c) Medical suppliers, including expendable and durable equipment.
  (d) Hearing aid vendors and suppliers of prosthetic eye equipment.
  (3) A home health agency.
  (4) If a practitioner performs a procedure that cannot be described by  one 
of the listed CPT® or HCPCS codes,  then  the  practitioner  shall  bill  the 
unlisted procedure code.  An unlisted procedure code shall only be reimbursed 
when the service cannot be properly described with  a  listed  code  and  the 
documentation supporting medical necessity includes all of the following:
  (a) Description of the service.
  (b) Documentation of the time, effort, and equipment necessary  to  provide 
the care.
  (c) Complexity of symptoms.
  (d) Pertinent physical findings.
  (e) Diagnosis.
  (f) Treatment plan.
  (5) The provider shall add a modifier code, found in Appendix A   of    the 
CPT® publication, as adopted by reference in R 418.10107,    following    the 
correct procedure  code  describing  unusual  circumstances  arising  in  the 
treatment of a covered injury or illness. When a modifier code   is   applied 
to  describe  a procedure, a report describing  the   unusual   circumstances 
shall  be  included with the charges submitted to the carrier.
  (6) Applicable modifiers from  table  10904  shall  be   added    to    the 
procedure code to describe  the  type  of   practitioner    performing    the 
service.  The required modifier codes for describing the practitioner are  as 
follows:

Table 10904 Modifier Codes -AA Anesthesia services  performed  personally  by 
anesthesiologist -AH When a licensed psychologist bills a diagnostic  service 
or a  therapeutic service, or both.
-AJ When a certified social worker bills a therapeutic service.
-AL A  limited  license  psychologist  billing  a  diagnostic  service  or  a 
therapeutic service.
-CS When a limited licensed counselor bills for a therapeutic service.
-GF Non-physician (nurse practitioner, advanced practice nurse  or  physician 
assistant) provides services in an office or clinic setting or in a  hospital 
setting.
-LC When a licensed professional counselor performs a therapeutic service.
-MF When a licensed marriage and  family  therapist  performs  a  therapeutic 
service.
-ML When a limited licensed marriage and family therapist performs a service.
-TC When billing for the technical component of a radiology service.
-QK When an anesthesiologist provides medical direction for not more  than  4 
qualified individuals being either certified registered nurse anesthetists or 
anesthesiology residents -QX When a certified  registered  nurse  anesthetist 
performs  a  service  under the medical direction of an anesthesiologist.
-QZ When  a  certified  registered  nurse  anesthetist  performs   anesthesia 
services without medical direction.

  History: 1998-2000 AACS; 2002 AACS; 2003 AACS; 2005 AACS.


R 418.10905  Billing for physical and occupational therapy.
  Rule 905. (1) A physical or occupational  therapist  shall  bill  procedure 
codes 97001-97799.   A  registered  occupational  therapist   or   licensed   
physical therapist in independent practice   shall   place   his   or   her   
signature  and license or certification number on the bill.
  (2) Only a   physician,   registered   occupational   therapist,   or   a   
licensed physical therapist  shall  bill  for  job   site   evaluation   or   
treatment.   The reimbursement for  these  procedures  shall  be  contractual 
between  the  carrier and provider and shall  be  billed  as  listed  in  the 
following table:
Code Descriptor WC500 Job  site  evaluation;  patient  specific,  initial  60 
minutes WC505 each additional 30 minutes, by contractual agreement WC550  Job 
site treatment; patient specific, initial 60 minutes WC555 each additional 30 
minutes, by contractual agreement WC600 Mileage for job  site  evaluation  or 
job site treatment per mile
  (3) Procedures 97760 and 97761 shall only be  reimbursed  when  billed  by  
a registered occupational or licensed physical therapist.
  (4) Only a licensed or registered physical  or   occupational   therapist   
shall bill for work hardening services, "by report" or "BR," procedure codes  
97545 and 97546.

  History: 2000 AACS; 2009 MR 12, Eff. July 7, 2009.


R 418.10907   Billing codes for site of service and type of service.
  Rule  907.  (1)  A  practitioner,  other  than  a  dentist,  when   billing 
practitioner services, shall identify the  site  of  service  and   type   of 
service  with numerical codes consistently used in the industry.  The  health 
care  services division of the workers' compensation  agency  shall   publish 
the  numerical codes in the Health Care Services Manual separate  from  these 
rules.

  History: 2000 AACS; 2005 AACS.


R 418.10909  Billing for home health services.
  Rule 909. (1)  Services  provided   by   a   home   health    agency    are 
considered  ancillary  services  requiring   a   physician's     prescription 
certifying  medical necessity. A copy of the prescription shall  be  attached 
to the bill.
  (2)  A  home  health  agency  shall  submit  charges  to    the    workers' 
compensation carrier using the UB-04 claim form.
  (3) A home  health  agency  shall  use  procedure  codes    from    "HCPCS, 
Medicare's National Level II Codes" adopted by reference  in   R    418.10107 
to  identify services provided.
  (4) A home health agency may not bill for the  services   of    a    social 
worker unless  the  certified  social  worker   is    providing     medically 
necessary therapeutic counseling.
  (5) A home health agency may bill supplies with 99070,  the  unlisted  CPT® 
code for miscellaneous supplies,  or  the  appropriate  supply   code    from 
"Medicare's National Level II Codes HCPCS"  as  adopted  by  reference  in  R 
418.10107.
  (6) When a procedure code is described by "HCPCS, Medicare's Level  II"  as 
per diem,  the  "by  report"  service  is  reimbursed   per    visit.    When 
"HCPCS, Medicare's Level II" describes a service as time-based  the   service 
is  "by report," and the  procedure  is  reimbursed  according  to  the  time 
provided.

  History: 2002 AACS; 2008 AACS.


R 418.10911   Billing requirements for ancillary services.
  Rule 911. (1) A bill for the following ancillary services shall  include  a 
copy of a written prescription by a licensed practitioner. Documentation of a 
prescription drug or medical supply in the clinical record  shall  constitute 
the prescription for services dispensed in a practitioner's office  or  in  a 
health care organization.
  (a) Prescription medications.
  (b) Medical supplies and equipment, except when dispensed by a facility  or 
health care organization.
  (c) Hearing aids, shoes, and wigs.
  (d) Home health services.
  (e) Orthoses and prostheses.
  (f) Physical and occupational therapy.

  History: 2000 AACS.


R 418.10912  Billing for prescription medications.
  Rule 912. (1) Prescription drugs may be dispensed to  an   injured   worker 
by either an outpatient pharmacy or a health care  organization  as   defined 
in these  rules.  These  rules  shall  apply  to  the   pharmacy   dispensing 
the prescription drugs to an injured worker only after the    pharmacy    has 
either  written  or  oral  confirmation  from   the    carrier    that    the 
prescriptions  or supplies are covered by workers' compensation insurance.
  (2) When a generic drug exists, the generic drug shall be dispensed.   When 
a generic drug does not  exist,  the  brand  name  drug  may  be  dispensed.
A physician may only write a  prescription  for  "DAW",  or    dispense    as 
written, when the generic drug has been utilized and found to be  ineffective
 or  has caused adverse effects for the  injured  worker.  A  copy   of   the 
medical  record documenting the medical necessity for  the  brand  name  drug 
shall be  submitted to the carrier.
  (3) A bill or receipt  for  a  prescription  drug  from    an    outpatient 
pharmacy, practitioner, or health care organization shall be   submitted   to 
the  carrier and shall include the name,  address,  and    social    security 
number  of  the injured worker. An outpatient pharmacy   shall    bill    the 
service  using  the universal pharmacy claim form or an invoice   and   shall 
include  the  national association board of  pharmacy  identification  number 
and the serial number  of the prescription drug.
  (4)  A  health  care  organization  or   physician    office     dispensing 
the prescription drug shall  bill  the  service  on  the  CMS   1500    claim 
form.
Procedure code 99070 shall be used to code the service and the national  drug 
code shall be used to describe the drug.
  (5) If an injured worker has paid for a prescription drug for   a   covered 
work illness, then the worker may send a receipt showing payment  along  with
 the drug information to the carrier for reimbursement.
  (6) An outpatient pharmacy or health care organization shall  include   all 
of the following information when submitting a bill for a prescription   drug 
to the carrier:
  (a) The brand or chemical name of the drug dispensed.
  (b) The manufacturer or supplier's name and the NDC, or    national    drug 
code from the "Red Book" as adopted by reference in R 418.10107.
  (c) The dosage, strength, and quantity dispensed.
  (d) The date the drug was dispensed.
  (e) The physician prescribing the drug.
  (7) A practitioner or  a  health  care  organization,   other    than    an 
inpatient hospital, shall bill WC700-G to describe the  dispense   fee    for 
each  generic prescription drug and WC700-B to describe the   dispense    fee 
for  each  brand name prescription drug.  A provider will only be  reimbursed 
for  1  dispense fee for  each  prescription  drug  in  a  10-day  period.  A 
dispense fee  shall  not be billed with "OTC"s, over-the-counter drugs.

  History: 2000 AACS; 2002 AACS; 2005 AACS; 2008 AACS.


R 418.10913  Billing for durable medical equipment and supplies.
  Rule 913. (1) Durable medical equipment (DME)  and  supplies    shall    be 
billed using the appropriate descriptor from HCPCS,    Medicare's    National 
Level  II codes, as referenced in R 418.10107, for the  service.    If    the 
equipment  or supply is billed using an unlisted or not  otherwise  specified 
code  and  the charge exceeds $35.00, then an invoice shall be included  with 
the bill.
  (2) Initial claims for  rental  or  purchased  DME  shall  be  filed   with 
a prescription for medical necessity, including  the  expected   time    span 
the equipment will be required.
  (3) Durable medical equipment may be billed as a rental  or  a  purchase.
If possible, the provider and carrier shall agree before dispensing the  item 
as to whether it should be a rental or a purchased item. With the   exception 
of oxygen equipment, rented DME  is  considered  purchased   equipment   once 
the monthly rental allowance exceeds the purchase price or payment   of    12 
months rental, whichever comes first.
  (a) If the  worker's  medical  condition  changes  or  does   not   improve 
as expected, then the rental may be discontinued in favor of purchase.
  (b) If death occurs, rental fees for equipment will terminate at  the   end 
of the month and additional rental payment shall not be made.
  (c) The return of rented equipment is the  dual  responsibility   of    the 
worker and the DME supplier. The  carrier  is  not  responsible   and   shall 
not  be required to reimburse for additional rental periods solely because of 
a delay in equipment returns.
  (d) Oxygen equipment shall be considered a rental as long as the  equipment 
is  medically  necessary.  The  equipment   rental     allowance     includes 
reimbursement for the oxygen contents.
  (4) A bill for an expendable medical supply shall include the  brand   name 
and the quantity dispensed.
  (5) A bill for a miscellaneous supply, for example; a  wig,    shoes,    or 
shoe modification, shall be submitted on an invoice if the supplier  is   not 
listed as a health care professional.

  History: 2000 AACS; 2006 AACS; 2008 AACS.


R 418.10915   Billing for anesthesia services.
  Rule 915. (1) Anesthesia services shall  consist  of  2  components.    The 
2 components are base units and time units.  Each anesthesia  procedure  code 
is assigned a value for  reporting  the  base  units.  The  base  units   for 
an anesthesia procedure shall  be   as   specified   in    the    publication 
entitled "Medicare  RBRVS:   The   Physicians'   Guide"   as    adopted    by 
reference  in  R 418.10107. The anesthesia codes, base units and instructions 
for billing  the anesthesia service shall be published  separate  from  these 
rules in the health care services manual.
  (2)  An  anesthesia  service  may   be   administered    by    either    an 
anesthesiologist, anesthesia  resident,  a   certified    registered    nurse 
anesthetist,    or    a  combination  of  a   certified   registered    nurse 
anesthetist,  and  a  physician providing medical direction  or  supervision.
  When  billing  for  both  the anesthesiologist and a  certified  registered 
nurse anesthetist, the anesthesia procedure code shall  be  listed    on    2 
lines  of  the  CMS  1500  with  the appropriate modifier on each line.
  (3) One of the  following  modifiers  shall  be  added  to  the  anesthesia 
procedure code to determine the appropriate payment for the time units:
  (a) Modifier -AA indicates the anesthesia  service  is   administered    by 
the anesthesiologist.
  (b)  Modifier  -QK   indicates   the    anesthesiologist    has    provided 
medical direction for a certified registered nurse  anesthetist,   CRNA,   or 
resident.
The  CRNA  or  resident  may  be  employed  by   either   a   hospital,   the 
anesthesiologist or may be self-employed.
  (c) Modifier -QX indicates the certified  registered   nurse    anesthetist 
has administered   the   procedure   under   the   medical    direction    of 
the anesthesiologist.
  (d) Modifier -QZ indicates the certified  registered   nurse    anesthetist 
has administered the complete anesthesia service without medical direction of
 an anesthesiologist.
  (4) Total anesthesia units shall be calculated by adding   the   anesthesia 
base units to the anesthesia time units.
  (5) Anesthesia services may be administered by any of the following:
  (a) A licensed doctor of dental surgery.
  (b) A licensed doctor of medicine.
  (c) A licensed doctor of osteopathy.
  (d) A licensed doctor of podiatry.
  (e) A certified registered nurse anesthetist.
  (f) A licensed anesthesiology resident.
  (6) If a surgeon provides the anesthesia service, the surgeon   will   only 
be reimbursed the base units for the anesthesia procedure.
  (7) If a provider bills physical status  modifiers,   then    documentation 
shall be included with the bill to  support  the  additional  risk  factors.
 When billed, the physical status  modifiers  are  assigned  unit  values  as 
defined  in the following table:

 Anesthesiology Physical Status Modifiers Unit  Value  P1  A  normal  healthy 
patient. 0 P2 A patient who has a mild systemic disease. 0 P3 A  patient  who 
has a severe systemic disease. 1 P4 A  patient  who  has  a  severe  systemic 
disease that is a constant  threat  to life. 2 P5 A moribund patient  who  is 
expected not to survive without the operation. 3  P6  A  declared  brain-dead 
patient whose organs are  being  removed  for  donor purposes. 0

  (8) Procedure code 99140 shall  be  billed  as  an  add-on   procedure   if 
an  emergency  condition,  as   defined   in   R    418.10108,    complicates 
anesthesia.
Procedure code 99140 shall be assigned  2  anesthesia  units.   Documentation 
supporting the emergency shall be attached to the bill.
  (9)  If  a  pre-anesthesia  evaluation  is  performed   and   surgery    is 
not subsequently performed, then the  service  shall  be  reported   as    an 
evaluation and management service.

  History: 2000 AACS; 2003 AACS; 2005 AACS.


R 418.10916  Rescinded.

  History: 1998-2000 AACS; 2002 AACS; 2003 AACS; 2006 AACS.


R 418.10918  Rescinded.

  History: 1998-2000 AACS; 2002 AACS.


R 418.10920   Billing for supplementary radiology supplies.
Rule 920. (1) If a description of a diagnostic radiology  procedure  includes 
the use of contrast materials, then  those  materials  shall  not  be  billed 
separately as they are included in the procedure.
  (2) A radiopharmaceutical diagnostic low  osmolar  contrast  materials  and 
paramagnetic contrast materials shall only be billed when "Current Procedural 
Terminology"  billing  instructions  indicate  supplies   shall   be   listed 
separately.
  (3) A supply for a radiology procedure shall be coded as provided  in  this 
rule.  A provider shall include an invoice documenting the wholesale price of 
the contrast material used  and  the  provider  shall   be   reimbursed   the 
wholesale price of the contrast material.

Code                               Descriptor    A4641          Supply     of 
radiopharmaceutical  diagnostic  imaging  agent  A4644        Supply  of  low 
osmolar contrast material (100-199 mgs. of iodine) A4645       Supply of  low 
osmolar contrast material (200-299 mgs. of iodine) A4646       Supply of  low 
osmolar contrast material (300-399 mgs. of iodine)

  History: 1998-2000 AACS.


R 418.10921  Facility billing.
  Rule 921. (1) Except for  a  freestanding  surgical  outpatient   facility, 
a licensed facility as defined in these rules shall submit  facility  charges 
on a UB-04 claim form to the carrier.   A  copy  of  the  UB-04  form   shall 
be published separate from these rules in a manual   distributed    by    the 
health care services  division  of  the  agency.   The  Official  UB-04  Data 
Specifications Manual referenced in these  rules  contains  instructions  for 
facility billing.
  (2) A facility billing for a practitioner service shall bill  charges    on 
the CMS 1500 claim form.

  History: 1998-2000 AACS; 2005 AACS; 2008 AACS.


R 418.10922  Hospital billing instructions.
  Rule 922. (1) A hospital shall  bill  facility  charges  on    the    UB-04 
national uniform billing claim form and shall include revenue codes, ICD.9.CM
 coding, HCPCS  codes,  and  CPT®  codes   to    identify    the    surgical, 
radiological, laboratory, medicine, and evaluation and management services.
This rule only requires that the following medical records be  attached  when 
appropriate:
  (a) Emergency room report.
  (b) The initial evaluation   and   progress   reports   every    30    days 
whenever physical medicine, speech, and hearing services are billed.
  (c) The anesthesia record when billing for a CRNA or anesthesiologist.
  (2) A properly completed  UB-04   shall   not   require    attachment    of 
medical records except for those in sub  rule  (1)  of  this  rule   to    be 
considered  for payment. Information required for reimbursement  is  included
 on  the  claim form.  A carrier may request any additional records  under  R 
418.10118.
  (3) If a hospital clinic,  other  than  an  industrial   or    occupational 
medicine clinic, bills under a  hospital's  federal  employer  identification 
number, then a hospital clinic facility service shall be identified by  using 
revenue  code 510 "clinic."
  (4) A hospital system-owned office practice shall bill services   on    the 
CMS 1500 claim form using the office site of service  and  shall   not   bill 
facility fees.
  (5) A hospital or hospital  system-owned   industrial    or    occupational 
clinic providing occupational health services shall bill services   on    the 
CMS  1500 claim form using the office site of  service  and  shall  not  bill 
facility fees.

  History: 1998-2000 AACS; 2003 AACS; 2006 AACS; 2007 AACS; 2008 AACS.




R 418.10923  Hospital billing for practitioner services.
  Rule 923. (1) A hospital  billing  for  practitioner  services,   including 
a certified registered nurse anesthetist,  a  physician,  a  nurse  who   has 
a specialty certification, and a physician's assistant, shall submit bills on 
a CMS 1500 form and the hospital shall  use   the    appropriate    procedure 
codes adopted by these rules. A  hospital  shall  bill    for    professional 
services provided in the hospital clinic setting as  practitioner    services 
on  a  CMS 1500 form using outpatient hospital for the site of  service.    A 
hospital  or hospital system-owned office practice  shall  bill  all   office 
services  as practitioner services on a CMS 1500 form using office or  clinic 
for the  site of service. A hospital or hospital system-owned  industrial  or
 occupational clinic  providing  occupational  health  services  for  injured 
workers shall  bill all clinic services as practitioner  services  on  a  CMS 
1500  using  office  or clinic  for  the  site  of  service.  A  hospital  or
 hospital  system-owned industrial  or  occupational  clinic  shall  not  use
 emergency   department evaluation and management procedure codes.  Radiology 
and laboratory  services may be billed as facility services on the UB-04.
  (2) A hospital billing for  the  professional  component  of   a    medical 
service, excluding physical medicine, occupational medicine,  or  speech  and
 hearing services shall bill the service on a  CMS  1500  claim  form  adding 
modifier  -26 identifying the bill is for the professional component of   the 
service.  The bill  shall  indicate  outpatient  hospital  for  the  site  of 
service. The  carrier shall pay the  maximum  allowable  fee  listed  in  the 
manual for the professional component of the procedure. If  the  professional 
component is not listed, then the  carrier  shall  pay  40%  of  the  maximum 
allowable fee.
  (3) A hospital billing for a radiologist's  or    pathologist's    services 
shall bill the professional component of the procedure on the CMS 1500  claim
 form and shall place modifier -26 after the appropriate  procedure  code  to 
identify the professional component of the service. The carrier shall pay the
 maximum allowable fee listed in the manual for  the  professional  component
 of  the procedure. If the professional component is  not  listed,  then  the
 carrier shall pay 40% of the maximum allowable fee.
  (4) A hospital billing for a certified   registered    nurse    anesthetist 
shall bill only time units of an anesthesiology procedure  and  use  modifier 
-QX with the appropriate anesthesia code, except in the absence  of   medical 
direction from a supervising anesthesiologist.

  History: 1998-2000 AACS; 2002 AACS; 2003 AACS; 2005 AACS; 2008 AACS.




R 418.10923b Billing for freestanding surgical outpatient facility, (FSOF).
  Rule 923b.  (1) A freestanding surgical outpatient facility  (FSOF)   shall 
be licensed by the department of public health, bureau of   health   systems, 
under part 208 of the code. The owner or operator of  the   facility    shall 
make  the facility available to other physicians, dentists,  podiatrists   or 
providers who comprise its professional staff.
  (a)  When  a  surgery  procedure  is  appropriately   performed   in    the 
freestanding surgical outpatient facility and Medicare has not   assigned   a 
grouper  number for that procedure, the  procedure  shall  be  considered  by 
report.
  (b) The freestanding surgical outpatient  facility  shall   be   reimbursed 
either the usual and customary charge or reasonable charge,   whichever    is 
less  for the procedure.
  (2)  Billing  instructions  in  this   rule   do   not    apply    to     a 
hospital-owned freestanding  surgical  outpatient  facility   billing    with 
the   same   tax identification number as the hospital.
  (3) A freestanding surgical outpatient facility,  licensed  by  the  state, 
shall bill the facility services on the CMS  1500  claim  form   and    shall 
include modifier SG to identify the service as the facility   charge.     The 
place  of service shall  be  "24."    The   appropriate   HCPCS    or    CPT® 
procedure  code describing the service performed shall be listed on  separate
 lines  of  the bill.
  (4) Modifier 50, generally indicating bilateral procedure is   not    valid 
for the FSOF claim. Procedures performed  bilaterally  shall  be  billed   on 
two separate lines of the claim form and shall be identified with  modifiers,
 LT for left and RT for right.
  (5)  A  freestanding  surgical  outpatient  facility   shall   only    bill 
for outpatient procedures which, in the opinion of the attending   physician, 
can be performed safely without requiring inpatient overnight hospital   care 
and are exclusive of such   surgical   and   related   care    as    licensed 
physicians ordinarily elect to perform in their private offices.
  (6) The CPT® procedure code billed by the facility is classified  according 
to groupers, as determined by center for Medicare  and  Medicaid  services.
The grouper number for each  procedure  code  is  published  in  the  federal 
register.
  (7) The payment for  the  surgical  code  includes  the  supplies  for  the 
procedure.
  (8) Laboratory procedures, durable medical equipment,  radiology  services, 
and items implanted into the body that remain in the body at discharge   from 
the facility may be billed separately.
  (9) The facility shall bill implant items with the  unlisted   CPT®    drug 
and supply code, 99070. A report listing a description of the implant  and  a 
copy of the facility's cost invoice shall be included  with  the  bill.  Some 
examples of implant items are plates, pins, screws, mesh.
  (10) When radiology procedures  are  performed   intra-operatively,    only 
the technical component shall be billed by the facility  and  reimbursed   by 
the carrier. The professional component  shall   be   included    with    the 
surgical procedure.  Pre-operative  and  post-operative  radiology   services 
may   be globally billed.
  (11) At no time shall the freestanding surgical outpatient  facility   bill 
for practitioner services on the facility bill.

  History: 2005 AACS; 2008 AACS.


R 418.10924   rescinded.

  History: 1998-2000 AACS; 2003 AACS.


R 418.10925  Billing requirements for other licensed facilities.
  Rule  925.  (1)  A  licensed  facility,  other   than   a    hospital    or 
freestanding surgical outpatient facility, shall bill the  facility  services 
on  the  UB-04 national uniform billing claim form  and  shall  include   the 
revenue  codes contained in the Official UB-04 Data  Specifications   Manual, 
ICD-9-CM  coding for  diagnoses  and   procedures,   and    CPT®    procedure 
codes  for  surgical, radiological, laboratory, and medicine  and  evaluation 
and management services.
  (2) Only the  technical  component  of  a  radiological  service    or    a 
laboratory service shall be billed  on  the  standardized   UB-04    national 
uniform  billing claim form.
  (3) All bills for the professional services shall be billed  on    a    CMS 
1500 claim form, using the appropriate CPT® procedure code and modifier.
  (4) A report describing the  services  provided  and  the   condition    of 
the patient shall be included with the bill.

  History: 1998-2000 AACS; 2003 AACS; 2005 AACS; 2008 AACS.



                   PART 10.  REIMBURSEMENT
               SUBPART A.  PRACTITIONER REIMBURSEMENT

R 418.101001  General rules for practitioner reimbursement.
  Rule 1001. (1) A provider that is authorized to  practice  in   the   state 
of Michigan shall receive the maximum allowable payment  in  accordance  with 
these rules.  A provider shall follow the  process   specified    in    these 
rules  for  resolving  differences  with  a  carrier  regarding  payment  for 
appropriate  health  care  services  rendered  to   an   injured   worker.
Reimbursement  shall  be  based upon the site of service. The  agency   shall 
publish  the  maximum  allowable payment for a  procedure  performed  in  the 
non-facility setting and  the  maximum  allowable  payment  for  a  procedure 
performed in the facility setting.
  (2) A carrier shall not make a  payment  for   a   service    unless    all 
required review activities pertaining to that service are completed.
  (3) A carrier's payment shall  reflect  any  adjustments  in    the    bill 
made through the carrier's utilization review program.
  (4) A carrier shall pay, adjust, or reject  a  properly   submitted    bill 
within 30 days of receipt.  The carrier shall notify the provider on  a  form 
entitled "Carrier's Explanation of Benefits" in a format specified  by    the 
agency.  A copy shall be sent to the injured worker.
  (5) A carrier shall not  make  a  payment  for  any   service    that    is 
determined inappropriate by the carrier's  professional  health  care  review 
program.
  (6) The carrier shall reimburse the provider a 3% late fee if   more   than 
30 calendar days elapse between a carrier's receipt of a  properly  submitted 
bill and a carrier's mailing of the payment.
  (7) If a procedure code has a maximum fee of "by  report,"   the   provider 
shall be paid its usual  and  customary  charge  or  the  reasonable  amount, 
whichever  is  less.   The  carrier  shall  provide  an  explanation  of  its 
determination that the fee is unreasonable or excessive  in  accordance  with 
these rules.

  History: 1998-2000 AACS; 2005 AACS; 2006 AACS.


R 418.101002   Conversion  factors  for  medical,  surgical,  and   radiology 
procedure codes; wage index  factors  for  freestanding  surgical  outpatient 
facility.
  Rule  1002.  (1)  The  workers'  compensation   agency   shall    determine 
the conversion factors for medical,  surgical,  and  radiology  procedures.
The conversion factor shall be used  by  the  workers'  compensation   agency 
for determining  the  maximum  allowable  payment  for   medical,   surgical, 
and radiology procedures. The maximum allowable payment shall  be  determined
 by multiplying the appropriate conversion factor times the  relative   value 
unit assigned to a procedure.   The  relative  value  units  are  listed  for
 the medicine, surgical, and radiology procedure codes in a manual   separate 
from these rules.   The  manual  shall  be  published   annually    by    the 
workers' compensation agency using codes adopted from  "Physicians'   Current 
Procedural Terminology  (CPT®)"  as  referenced  in  R   418.10107(a).    The
  workers' compensation agency shall determine the relative values  by  using 
information found in the "Medicare RBRVS: The Physicians'Guide"  as   adopted 
by  reference in R 418.10107(c).
  (2)  The  conversion  factor  for  medicine,  radiology,    and    surgical 
procedures shall be $49.22 for the year 2006 and shall be effective for dates 
of service on the effective date of these rules.
  (3) The wage index used to determine the  maximum  allowable  payment   for 
a surgery performed in a freestanding surgical  outpatient    facility    for 
2006 shall be 1.0678 and shall be effective for dates  of  service   on   the 
effective date of these rules.

  History: 1998-2000 AACS; 2002 AACS; 2003 AACS; 2004 AACS; 2005  AACS;  2006 
AACS.


R 418.101002a  Conversion factor for practitioner services.
  Rule  1002a.  (1)  The  workers'  compensation  agency  shall   determine   
the conversion factor for  medical,  surgical,  and  radiology  procedures.   
The conversion factor shall be used  by  the  workers'  compensation  agency  
for determining  the  maximum  allowable  payment  for  medical,  surgical,   
and radiology procedures. The maximum allowable payment shall  be  determined 
 by multiplying the appropriate conversion factor times the relative  value   
unit assigned to a procedure.   The  relative  value  units  are  listed  for 
 the medicine, surgical, and radiology procedure codes in a manual  separate  
from these rules.   The  manual  shall  be  published   annually   by   the   
workers' compensation agency using codes adopted from "Physicians'  Current   
Procedural Terminology  (CPT®)"  as  referenced  in  R  418.10107  (a).   The 
  workers' compensation agency shall determine the relative values by using   
information found in the "Medicare RBRVS: The Physicians' Guide"  as  adopted 
by  reference in R 418.10107 (c).
  (2)  The  conversion  factor  for  medicine,  radiology,   and   surgical   
procedures shall be $50.70 for the year 2009 and shall be effective for dates 
of service on the effective date of these rules.

  History: 2007 AACS; 2008 AACS; 2009 MR 12, Eff. July 7, 2009.


R 418.101002b  Wage  index  factor  for  freestanding  surgical    outpatient 
facilities.
  Rule 1002b.  The wage index used  to  determine  the   maximum    allowable 
payment for  a  surgery  performed  in  a  freestanding  surgical  outpatient 
facility  shall be determined by the agency and  shall  be    published    in 
chapter  15  of  the manual separate from these rules.  The  determined  wage 
index is an average  of the data published by Medicare for ambulatory surgery
 centers  in  southeast Michigan for the year prior to the effective date  of 
these rules.

  History: 2007 AACS.


R 418.101003  Reimbursement for "by report" and ancillary procedures.
  Rule 1003. (1) If a procedure code does not have a listed relative value,   
or is noted BR, then the  carrier  shall  reimburse  the  provider's  usual   
and customary charge or reasonable  payment,  whichever  is  less,   unless   
otherwise specified in these rules.
  (2) The following ancillary services are by report and the provider shall   
be reimbursed either  at  the  practitioner's  usual  and  customary  charge  
or reasonable payment, whichever is less:
  (a) Ambulance services.
  (b) Dental services.
  (c) Vision and prosthetic optical services.
  (d) Hearing aid services.
  (e) Home health services.
  (3) Orthotic and prosthetic procedures, L0000-L9999, shall be  reimbursed   
by the carrier at Medicare plus 5%.  The health  care   services   division   
shall publish maximum allowable  payments  for  L-code  procedures  in  the   
manual separate from these rules.  Orthotic and prosthetic procedures   not   
included in the manual shall be considered by report procedures and require a 
 written description accompanying the charges on the CMS-1500  claim  form.   
The  report shall include date of service, a description of  the  services(s) 
provided, the time involved, and the charge for materials and components.

  History: 1998-2000 AACS; 2005 AACS; 2006 AACS; 2008 AACS; 2009 MR 12, Eff.
July 7, 2009.


R 418.101003b  Reimbursement for durable medical equipment and supplies.
  Rule 1003b.  (1) The carrier shall reimburse  durable   medical   equipment 
(DME) and supplies at Medicare plus 5%. The health  care  services   division 
shall publish the maximum allowable payments for DME and  supplies   in   the 
manual separate from these rules.
  (2) Rented DME shall be identified on the provider's bill by RR.   Modifier 
NU will identify the item as purchased, new.
  (3) If a DME or supply exceeding $35.00 is not listed in the fee  schedule, 
or if  the  service  is  billed  with  a  not  otherwise   specified    code, 
then reimbursement shall be invoice cost plus a percent mark-up as follows:
  (a) Invoice cost of $35.01 to $100 shall receive cost plus 50%.
  (b) Invoice cost of $100.01 to $250.00 shall receive cost plus 30%.
  (c) Invoice cost of $250.01 to $700.00 shall receive cost plus 25%.
  (d) Invoice cost of $700.01 or higher shall receive cost plus 20%.

  History: 2006 AACS.

R 418.101003a  Reimbursement for dispensed medications
  Rule 101003a. (1) Prescription medication  shall  be  reimbursed   at   the 
average wholesale price (AWP) minus 10%,  as  determined  by  the  Red  Book, 
referenced in R 418.10107, plus a dispense fee.
  (a) The dispense fee for a brand name drug shall  be  $3.50  and  shall  be 
billed with WC700-B.
  (b) The dispense fee for a generic drug shall be  $5.50  and    shall    be 
billed with WC700-G.
  (2) Over-the-counter drugs (OTC's), dispensed by  a  provider  other   than 
a pharmacy, shall be dispensed in 10-day quantities and shall  be  reimbursed 
at the average wholesale price,  as  determined  by  the   Red    Book,    or 
$2.50, whichever is greater.

  History: 2008 AACS.


R 418.101004   Modifier code reimbursement.
  Rule 1004. (1) Modifiers may be  used  to  report  that  the   service   or 
procedure performed has been altered by a specific circumstance but does  not 
change the definition  of  the  code.  This  rule  lists    procedures    for 
reimbursement  when certain modifiers  are  used.  A  complete   listing   of 
modifiers  are  listed  in Appendix A of "Current   Procedural    Terminology 
CPT®",  and  Appendix  1  of  "Medicare's  Level  II  Codes"  as  adopted  by 
reference in R 418.10107.
  (2) When modifier code  -25  is  added  to  an  evaluation  and  management 
procedure code, reimbursement shall  only  be  made  when  the  documentation
 provided supports  the  patient's  condition    required    a    significant 
separately identifiable evaluation and management service  other   than   the 
other  service provided or beyond the usual  preoperative  and  postoperative 
care.
  (3) When  modifier  code  -26,  professional  component,  is  used  with  a 
procedure, the professional component shall be paid.
  (4) If a  surgeon  uses  modifier  code  -47  when  performing  a  surgical 
procedure, then anesthesia services  were  provided  by  the   surgeon    and 
the  maximum allowable payment  for   the   anesthesia   portion    of    the 
service  shall  be calculated by multiplying the base unit of the appropriate 
anesthesia code by $42.00.  No additional payment is allowed for time units.
  (5) When modifier code -50 or -51 is used with surgical  procedure    codes 
the services shall be paid according to the following as applicable:
  (a) The primary procedure at  not  more  than   100%   of    the    maximum 
allowable payment or the billed charge, whichever is less.
  (b) The secondary procedure and the remaining procedure or  procedures   at 
not more than 50%  of  the  maximum  allowable  payment   or    the    billed 
charge, whichever is less.
  (c) When multiple injuries occur in different areas of  the    body,    the 
first surgical procedure in each part of the body shall be  reimbursed   100% 
of  the maximum allowable payment or billed charge, whichever  is  less,  and 
the second and remaining  surgical  procedure  or   procedures    shall    be 
identified  by modifier code -51 and shall be reimbursed at  50%    of    the 
maximum  allowable payment or billed charges, whichever is less.
  (d) When modifier -50 or -51 is used  with  a  surgical  procedure  with  a 
maximum allowable payment of BR, the maximum allowable payment shall be   50% 
of  the provider's usual and customary  charge  or  50%  of  the   reasonable 
amount, whichever is less.
  (6) The  multiple  procedure  payment  reduction  shall  be   applied    to 
the technical  component  for  radiological  imaging  procedures   performed
 on contiguous parts of the body.  When   modifier   -51   is    used    with 
specified diagnostic radiological imaging procedures, the  payment  for   the 
technical component of the procedure shall be reduced by 50% of the   maximum 
allowable payment.  A table listing these involved families of codes shall be 
published by the agency in a manual separate from these rules.
  (7) When modifier code -TC, technical  services,  is  used   to    identify 
the technical component of a radiology procedure, payment shall be made   for 
the technical component only. The  maximum  allowable   payment    for    the 
technical portion of the radiology procedure is designated in the  manual  by 
-TC.
  (8) When modifier -57, initial decision to perform surgery, is   added   to 
an evaluation and management procedure  code,  the   modifier    -57    shall 
indicate that a consultant has taken over the case and the consultation  code
 is  not part of the global surgical service.
  (9) When both surgeons use modifier -62   and   the   procedure    has    a 
maximum allowable payment, the maximum allowable payment for  the   procedure 
shall  be multiplied by 25%.  Each surgeon shall be paid 50% of the   maximum 
allowable payment times 25%, or  62.5  %  of  the  MAP.   If   the    maximum 
allowable  payment for the procedure is BR, then the reasonable amount  shall 
be  multiplied  by 25% and be divided equally between the surgeons.
  (10) When modifier code -80  is  used  with  a  procedure,   the    maximum 
allowable payment for  the  procedure  shall  be   20%   of    the    maximum 
allowable  payment listed in these rules, or the billed charge, whichever  is 
less.  If a maximum payment has not been established and the procedure is BR, 
then payment  shall be 20% of the reasonable  payment  amount  paid  for  the 
primary procedure.
  (11) When modifier code -81 is used with a  procedure  code  that   has   a 
maximum allowable payment, the maximum allowable payment for  the   procedure 
shall  be 13% of the maximum allowable payment listed in  these   rules    or 
the  billed charge, whichever is less.  If modifier code -81 is used  with  a 
BR procedure, then the maximum allowable payment for the procedure  shall  be
 13%  of  the reasonable amount paid for the primary procedure.
  (12) When modifier -82 is used and the  assistant  surgeon  is  a  licensed 
doctor of medicine, doctor of osteopathic medicine and surgery,   doctor   of 
podiatric medicine, or a doctor of dental surgery, the  maximum   level    of 
reimbursement shall be the same as for  modifier  -80.   If   the   assistant 
surgeon  is  a physician's assistant,  the  maximum  level  of  reimbursement 
shall be  the  same as modifier  -81.    If   a   person   other    than    a 
physician  or  a  certified physician's assistant bills using  modifier  -82, 
then the charge  and  payment for the service is reflected  in  the  facility 
fee.
  (13) When modifier -GF is billed with  evaluation   and    management    or 
minor surgical services, the carrier shall reimburse the procedure  at    85% 
of  the maximum allowable payment, or  the  usual  and   customary    charge, 
whichever  is less.

  History: 1998-2000 AACS; 2005 AACS; 2007 AACS.


R 418.101005 Reimbursement for home health services.
  Rule 1005. (1)  Home  health  services  are   reimbursed    "by    report," 
requiring submission of a report with the charges on the UB-04 claim  form.
The carrier shall reimburse  the  home  health  agency  according   to   each 
"by  report" procedure listed on the UB-04, billed with    the    appropriate 
HCPCS  code  in accord with R 418.10909.
  (2) Home health services shall be reimbursed by the  carrier   at    either 
the provider's usual and customary  charge  as  defined  by  these  rules  or 
reasonable amount, whichever is less.
  (3) Services listed in  "HCPCS,  Medicare  Level  II  Codes"   as   adopted 
by reference in R 418.10107 as per diem shall be  reimbursed  per   diem   or 
per visit in accord with the description of the  code.  The  per  diem  visit 
shall be either at the provider's usual and customary  charge  or  reasonable
 amount, whichever is less.
  (4) Supplies and  durable  medical  equipment  (DME)  shall  be  reimbursed 
pursuant to these rules.

  History: 2002 AACS; 2007 AACS; 2008 AACS.


R 418.101006 Reimbursement for mental health services.
  Rule 1006. (1) A carrier shall only  reimburse  procedure  codes   90805,   
90807, 90809, 90811, 90813, 90815, 90817, 90819, 90822, 90824, 90827, 90829,  
90862, 90865, and 90870 when billed by a psychiatrist (an M.D. or D.O).
  (2) A licensed psychologist or a limited license psychologist billing  for  
a diagnostic procedure shall be paid  the  maximum  allowable  payment   or   
the practitioner's usual and customary fee, whichever is less.
  (3) A licensed psychologist billing  for  a  therapeutic  service   shall   
use modifier -AH  and  shall  be  paid  the  maximum  allowable  payment  or  
the practitioner's usual and customary charge, whichever is less.
  (4) For the following providers, therapeutic mental health services shall   
be  reimbursed  at  85%  of  the  maximum  allowable   payment,   or   the    
practitioner's usual  and  customary  charge,  whichever  is  less.  If   a   
procedure  code  has  a maximum allowable payment of "by report," the maximum 
allowable  payment  shall  be  85%  of  the  reasonable   payment,   or   the 
practitioner's usual  and  customary charge, whichever is less:
  (a) -AL limited license psychologist.
  (b) -AJ certified social worker.
  (c) -LC licensed professional counselor.
  (d) -MF licensed marriage and family therapist.
  (5) For  the  following  providers,  mental  health  services  shall   be   
reimbursed at 64% of the maximum allowable payment,  or  the  practitioner's  
usual  and customary charge, whichever is less.  If  a  procedure  code  has  
a  maximum allowable payment of  "by  report,"  then  the  maximum  allowable 
payment shall be 64% of the reasonable  payment,  or   the   practitioner's   
usual  and  customary charge, whichever is less:
  (a) -CS limited licensed counselor.
  (b) -ML limited licensed marriage and family therapist.

  History: 1998-2000 AACS; 2009 MR 12, Eff. July 7, 2009.


R 418.101007  Reimbursement for anesthesia services.
  Rule 1007. (1) The carrier shall determine the  maximum  allowable  payment 
for anesthesia services by adding the base units  to  the  time  units.   The 
carrier shall reimburse anesthesia services at either the  maximum  allowable 
payment, or the practitioner's usual and customary charge, whichever is less.
 Each anesthesia base unit shall be multiplied by $42.00 to determine payment 
for the base procedure.
  (a) Anesthesia base units shall only be  paid  to  an  anesthesiologist,  a 
surgeon who provides the anesthesia and performs the surgery, or a  certified 
registered nurse anesthetist providing anesthesia without  medical  direction 
of the anesthesiologist.  Only 1 practitioner shall be  reimbursed  for  base 
units, documented by the anesthesia record.
  (2) The carrier shall reimburse the time units by the total minutes  listed 
in the "days" or "units" column and the alpha modifier added to the procedure 
code.  Time units are reimbursed in:
  (a) Increments of 15 minutes or portions thereof, for administration of the 
anesthesia.
  (b) Increments of 30 minutes or portions thereof, for supervision of a CRNA.
  (c) In no instance shall less than 1 time unit be reimbursed.
  (3) The maximum allowable payment for anesthesia time shall  be  calculated 
in the following manner:
  (a) If the anesthesiologist administers the anesthesia, then  the  modifier 
shall be -AA and the maximum payment shall be $2.80 per minute.
  (b) If the anesthesiologist supervises a CRNA, then the modifier  shall  be 
-SA and the maximum payment shall be $1.40 per minute.
  (c) If a CRNA supervised by an anesthesiologist administers the anesthesia, 
then the modifier shall be -QX and the maximum payment  shall  be  $2.80  per 
minute.
  (d) If a CRNA administers without supervision of the anesthesiologist, then 
the modifier shall be -QZ and the maximum payment shall be $2.80 per minute.

  History: 1998-2000 AACS.


R 418.101015  General rules for facility reimbursement.
  Rule 1015.  (1) A facility licensed by  the  state  of    Michigan    shall 
receive the maximum allowable payment in accordance with these   rules.   The 
facility shall follow the process specified in these rules   for    resolving 
differences with a carrier regarding payment for the    appropriate    health 
care  services rendered to an injured worker.
  (2) The carrier or its designated  agent  shall  assure  that   the   UB-04 
national uniform billing claim form is completed correctly before payment.  A 
carrier's payment shall reflect any adjustments in the bill made through  the 
carrier's utilization review program.
  (3) A carrier shall pay, adjust or reject a properly submitted bill  within 
30 days of receipt, sending notice on a form entitled "Carrier's  Explanation 
of Benefits" in a format specified  by  the  agency.  The    carrier    shall 
reimburse the facility a 3% late fee if more than 30 days elapse  between   a 
carrier's receipt of a properly submitted bill and a carrier's mailing of the 
payment.
  (4) Submission of  a  correctly  completed  UB-04  claim  form   shall   be 
considered to be a properly submitted bill.  The  following  medical  records 
shall also  be attached to the facility charges as applicable:
  (a) Emergency room report.
  (b) The initial evaluations  and   progress   reports   every    30    days 
whenever physical medicine, speech and  hearing  services  are  billed  by  a 
facility.
  (c) The anesthesia record whenever the facility bills for the services   of 
a CRNA or anesthesiologist.
  (5) Additional records not  listed  in  subrule  (4)  of  this   rule   may 
be requested by the carrier and shall be  reimbursed  in  accordance  with  R 
418.10118.

  History: 2000 AACS; 2005 AACS; 2008 AACS.


R 418.101016 Reimbursement; payment ratio methodology.
  Rule 1016. (1) A  hospital  licensed   in   Michigan   billing   facility   
services shall be reimbursed using the  maximum  payment  ratio  methodology  
for  the following services:
  (a) Inpatient or observation care.
  (b) Emergency department services.
  (c) Occupational, physical, and speech therapy services.
  (d) Outpatient surgeries.
  (e) Laboratory services and outpatient services.
If a carrier pays a properly submitted bill or unadjusted portion of the bill 
within 30 days of receipt, then the payment is calculated by multiplying  the 
charges times the hospital's maximum payment  ratio  times  a  multiplier  of 
107%. If a carrier pays the bill after 30 days, then the multiplier shall  be 
110% allowing for a 3% late fee.
  (2) When a hospital outside the  state  of  Michigan  submits  a  bill  for 
facility services, the carrier may initially  process  payment   by   using   
the  method described in subrule (1) of this  rule,  applying  the  average   
maximum  payment ratio, as published in the health  care  services  manual.   
If   the   facility  located  outside  of   Michigan   does   not   accept    
reimbursement  according  to Michigan health care services rules, then  the   
carrier  shall  negotiate  the charges  with  the  out-of-state  facility  or 
reimburse the facility according to the laws of the state where the  facility 
is located.
  (3) If applying the ratio methodology results in an amount greater   than   
the hospital's charge, the carrier shall reimburse  the  hospital's  charge.  
The only time a carrier shall pay in excess  of  the   charge   is   if   a   
properly submitted bill was not paid within 30 days and,  in  that  instance, 
the carrier shall reimburse the charge plus a 3% late fee.
  (4) Observation care shall not be for more  than  24   hours.    If   the   
patient does not meet admission criteria according to the  length  of  stay   
guidelines, then the patient shall be discharged from observation care.

  History: 1998-2000 AACS; 2005 AACS; 2007 AACS; 2009 MR  12,  Eff.  July  7, 
2009.


R 418.101017   Rescinded.

  History: 1998-2000 AACS; 2004 AACS; 2005 AACS; 2007 AACS.


R 418.101018   Rescinded.

  History: 1998-2000 AACS; 2007 AACS.


R 418.101019   Rescinded.

  History: 1998-2000 AACS; 2007 AACS.


R 418.101022  Facility  reimbursement  excluding  hospital  or   freestanding 
surgical outpatient facility.
  Rule 1022. (1) When the following licensed facilities provide  services  to 
an injured worker and bill  the  carrier,  the  billed  services   shall   be 
considered by report:
  (a) Nursing home.
  (b) County medical care facility.
  (c) Hospice.
  (d) Hospital long-term care unit.
  (e) Intermediate care facility or skilled nursing facility.
  (2) A licensed facility in subrule (1) of this rule shall   be   reimbursed 
by its usual and customary  charge  or  reasonable  amount  for  the  service 
provided, whichever is less.  If a carrier does not reimburse  the   facility 
within  30 days of receipt of a properly submitted bill,  the  carrier  shall 
reimburse the facility an additional 3% late fee.

  History: 1998-2000 AACS; 2005 AACS.


R 418.101023  Reimbursement for  freestanding  surgical  outpatient  facility 
service.
  Rule  1023.  (1)  Reimbursement  for  surgical  procedures  performed  in a 
freestanding surgical  outpatient  facility   shall    be    determined    by 
using grouper rates  as  determined  by  Medicare  and  published   in    the 
Federal Register. An allowable rate is assigned to each  grouper   and    the 
payment  is determined by multiplying the grouper rate times  a  wage  index.
The rates  for the groupers shall be published by the agency in  the   Health 
Care  Services Manual. The  wage  index  shall   be   determined    by    the 
workers'  compensation agency and shall  be  published  in  the  Health  Care 
Services Manual.
  (2) The state of Michigan workers' compensation  health    care    services 
rules shall adopt the payment system described in subrule (1) of  this   rule 
adding 80% to the rate reflecting  a  payment  that  is  80%   higher    than 
Medicare.  The formula for determining the maximum allowable  payment   (MAP) 
for  a  surgical procedure performed in a  freestanding  surgical  outpatient 
facility  shall  be as follows: (grouper rate) x (1.8) x (wage-index).
  (3) When 2 or more  surgical  procedures  are  performed  in    the    same 
operative session, the facility shall be reimbursed at 100% of  the   maximum 
allowable payment or the facility's usual and customary charge, whichever  is 
less,  for the procedure classified in the  highest  payment    group.    Any 
other  surgical  procedures  performed  during  the  same  session  shall  be 
reimbursed  at   50%   of  the  maximum  allowable  payment  or  50%  of  the 
facility's  usual  and  customary charge, whichever is less. A facility shall 
not un-bundle surgical  procedure codes when billing the services.
  (4) When an eligible procedure is  performed  bilaterally,  each  procedure 
shall be listed on a separate line of the claim form and shall be  identified
 with LT for left and RT for right. At no time shall modifier 50   be    used 
by  the facility to describe bilateral procedures.
  (5)  If  an  item  is  implanted  during  the   surgical   procedure    and 
the freestanding surgical outpatient facility bills the implant and  includes 
the copy of the invoice, then the implant shall be reimbursed at the cost  of 
the implant plus a percent markup as follows:
  (a) Cost of implant: $1.00 to $500.00 shall receive cost plus 50%.
  (b) Cost of implant: $500.01 to $1000.00 shall receive cost plus 30%.
  (c) Cost of implant: $1000.01 and higher shall receive cost plus 25%.
  (6) Laboratory services shall be  reimbursed  by  the   maximum   allowable 
payment as determined in R 418.101503.
  (7) When a radiology  procedure  is  performed   intra-operatively,    only 
the technical component shall be billed by the facility  and  reimbursed   by 
the carrier. The professional component  shall   be   included    with    the 
surgical procedure.  Pre-operative  and  post-operative  radiology   services 
may   be globally billed.
  (8)  When  the   freestanding   surgical    facility    provides    durable 
medical equipment, the items shall be reimbursed in accord with R 418.101003b.

  History: 2005 AACS; 2006 AACS; 2008 AACS.


                        PART 11.  HOSPITAL PAYMENT RATIO


R 418.101101  Calculation  and  revision  of  payment  ratio  for    Michigan 
hospitals.
  Rule 1101. (1) The workers' compensation agency shall  annually   calculate 
and revise, under the provisions of 1969 PA 306, 24.201 et  seq.   MCL,   the 
payment ratios for all Michigan hospitals.  The calculation shall   be   made 
using  a hospital's most recent fiscal year  information  that  is  submitted
 to  the Michigan  department  of  community   health,    medical    services 
administration, preceding each annual  calculation.   The  information   used 
shall  be  that reported to the Michigan department of   community    health, 
medical  services administration, on  the  hospital's  statement  of  patient 
revenues and operating expenses, G2  worksheet.   The  workers'  compensation 
agency shall complete  the payment ratio calculation between September 1  and 
October 1, or the  earliest  date  when  the  figures  are   available   from 
Michigan  department  of  community health and shall annually   publish   the 
hospital  ratio  calculations  in  a separate manual effective for  dates  of 
service on or after the effective date of these rules.
  (2)   The   workers'   compensation    agency     shall     calculate     a 
hospital's cost-to-charge ratio by dividing each hospital's  total  operating 
expenses  by total patient revenues as reported on the  hospital's  statement
 of  patient revenues and operating expenses, G2 worksheet.

  History: 1998-2000 AACS; 2004 AACS; 2005 AACS.


R 418.101102  Calculation and revision of payment ratio for hospitals outside 
Michigan.
  Rule 1102. The workers' compensation  agency  shall   annually    calculate 
and revise, under the provisions of 1969 PA 306, as  amended,  being  §24.201
 et seq. of the MCL, at the same time as  calculating   Michigan   hospitals' 
payment ratios, a weighted  state  average  payment  ratio  to  be  used  for 
hospitals  that are located outside the state  of  Michigan.    The   payment 
ratio  shall  be calculated by dividing the total hospital operating expenses 
for Michigan  by the total  hospital  patient  revenues  for   Michigan    as 
reported  under  R 418.1101(1).

  History: 1998-2000 AACS; 2005 AACS.


R 418.101103  Adjustments to hospital's payment ratio.
Rule 1103. (1) A hospital may apply to the agency for an  adjustment  of  the 
hospital's maximum payment ratio.
  (2) The hospital shall apply for an adjustment on a   form   and    in    a 
manner prescribed by the workers' compensation agency.
  (3) If the agency  determines  that   a   hospital's   ratio    of    total 
operating expenses to total patient revenues, as reported on the   hospital's 
statement of patient revenues and operating expenses, G2 worksheet,   for   a 
hospital's  most  recent  fiscal  year  is  higher  than  the  payment  ratio 
calculated according to R 418.1101, so that the  amount  of  underpayment  is 
more than $100,000.00 or is equal to or  greater  than  2/10  of  1%  of  the 
hospital's  operating  expenses for the year, then the  agency  shall  revise 
the payment ratio and shall notify the  hospital  and  all  carriers  of  the 
revised payment  ratio  within  45  days after  the  receipt  of  a  properly 
submitted request for an adjustment.
  (4) If a hospital's request for an adjustment  to  the  hospital's  payment 
ratio is denied by the workers' compensation agency, then a   hospital    may 
request reconsideration and appeal of the agency's action    regarding    the 
hospital's request for adjustment of its payment ratio.

  History: 1998-2000 AACS; 2005 AACS.


R 418.101104  Request for adjustment to  hospital's  maximum  payment  ratio; 
agency's response.
  Rule 1104. (1) Within 60 days of  the  agency's  receipt  of  a  hospital's 
request for  adjustment  to  the  hospital's  maximum  payment   ratio,   the 
workers' compensation agency shall notify the hospital of the action  on  the 
adjustment request and shall notify the hospital of  the   hospital's   right 
to  provide additional information to request reconsideration of the agency's 
action.
  (2) The workers' compensation agency shall also furnish the  hospital  with 
an appeal form.  The appeal form shall include  an   explanation    of    the 
appeal process.

  History: 1998-2000 AACS; 2005 AACS.


R 418.101105  Agency's action on request for adjustment  of  maximum  payment 
ratio; hospital's appeal.
  Rule 1105. (1) If a hospital is in disagreement with the action  taken   by 
the workers' compensation agency on  its  request  for  adjustment   of   the 
hospital's maximum payment ratio, then a hospital  may,  within  30  days  of 
receipt of  the agency's action on the hospital's  request   for   adjustment 
to  its  maximum payment ratio, deliver or mail an  appeal  of  the  agency's
 action  to  the agency.  The appeal shall include a detailed  statement   of 
the  reasons  for disagreement  and  shall  request  reconsideration  of  the 
agency's action on  the hospital's request for adjustment.
  (2) The workers' compensation agency shall hold a hearing within  30   days 
of the receipt of a hospital's appeal under section 847 of the act.

  History: 1998-2000 AACS; 2005 AACS.


        PART 12.  Carrier's professional health care review program


R 418.101201  Carrier's health care review program.
  Rule 1201. (1) The carrier shall have both a technical health  care  review 
program and a professional health care review program.
  (2) Health care review shall be conducted in a reasonable manner  on  bills 
submitted by a provider for health  care  services  furnished  because  of  a 
covered injury or illness arising out of and in the course of employment.

  History: 1998-2000 AACS.


R 418.101203  Carrier's technical health care review program.
  Rule 1203. Under the technical health  care  review  program,  the  carrier 
shall do all of the following:
  (a) Determine the  accuracy  of  the  procedure  coding.   If  the  carrier 
determines, based upon review of the bill  and  any  related  material  which 
describes the procedure performed,  that  the  procedure  is  incorrectly  or 
incompletely coded, then the carrier may re-code  the  procedure,  but  shall 
notify the provider of the reasons for the recoding within 30 days of receipt 
of the bill under part 13 of these rules.
  (b) Determine that the amount billed for a procedure does  not  exceed  the 
maximum allowable payment established by these rules.  If the  amount  billed 
for a procedure exceeds the maximum allowable payment, then the carrier shall 
reimburse the maximum allowable payment for that procedure.
  (c) Identify those bills and case records which, under R 418.101205,  shall 
be subject to professional health care review.

  History: 1998-2000 AACS.


R 418.101204  Carrier's professional health care review program.
  Rule 1204. (1) A carrier may have  another  entity   perform   professional 
health care review activities on its behalf.
  (2)  The  workers'  compensation  agency  shall   certify   a     carrier's 
professional health care review program pursuant to R 418.101206.
  (3) The carrier shall submit  a  completed  form   entitled    "Application 
for Certification of the Carrier's Professional Health Care  Review  Program"
 to the agency.  If the carrier is a self-insured employer  or   self-insured 
group fund, then the service company information shall be included   on   the 
form  in addition to the carrier and review company information. In  addition
 to  the completed form, the carrier shall submit all of the following:
  (a) The methodology used to perform professional review.
  (b)  A  listing  of  the  licensed,  registered,  or    certified    health 
care professionals reviewing the health care bills or establishing guidelines
 for technical  review.   In  addition,  the  proof  of  current   licensure
 and qualifications for the health care professionals shall be included  with
 the completed application.
  (c) A list of the carrier's peer review staff, including specialty.
  (4) The workers'  compensation  carrier  as  defined   by    these    rules 
maintains full responsibility for compliance with these rules.
  (5) The carrier  shall  determine   medical   appropriateness    for    the 
services provided in connection with the treatment of a  covered  injury   or 
illness, using  published,  appropriate  standard  medical   practices    and 
resource documents.  Utilization review shall be performed using  1  or  both
 of  the following approaches:
  (a) Review by licensed, registered, or certified health care professionals.
  (b)  The  application  by  others  of  criteria  developed   by   licensed, 
registered, or certified health care professionals.
  (6) The licensed, registered, or certified health care professionals  shall 
be involved in determining the carrier's response to a request by a  provider 
for reconsideration of its bill.
  (7) The licensed, registered, or certified  health    care    professionals 
shall have suitable occupational injury or disease  expertise,  or  both,  to 
render an informed clinical judgment on the medical  appropriateness  of  the
 services provided.
  (8) When peer review is utilized, a health  care  professional    of    the 
same specialty type as the provider of  the  medical  service  shall  perform
 the review.

  History: 1998-2000 AACS; 2003 AACS; 2005 AACS.


R 418.101205  Scope of professional health care review.
  Rule 1205. (1) The carrier, or  it's  review  company,  shall  review  case 
records and health-service bills, or both, under the professional health care
 review program as follows:
  (a) A case where  health  care  service  payments,   excluding    inpatient 
hospital care, exceed $20,000.00.
  (b) A case involving inpatient hospital care.
  (2) The carrier or other entity may at any time review  any   case   record 
or bill  which  the  carrier  or  the   other     entity     believes     may 
involve inappropriate, insufficient, or excessive care.

  History: 2000 AACS; 2005 AACS.


R 418.101206  Certification of professional health care review program.
  Rule 1206. (1)  The  workers'  compensation  agency  shall   certify    the 
carrier's professional health care review program.
  (2) A carrier, or the reviewing entity on behalf of  the   carrier,   shall 
apply to the agency for certification  of  a  carrier's  professional  health
 care review program in the manner prescribed by the  workers'   compensation 
agency.
The carrier shall submit a copy of "The  Carriers  Explanation  of  Benefits" 
form utilized to notify providers of payment decisions.
  (3) A carrier shall  receive  certification  if  the   carrier    or    the 
carrier's review company provides to the  agency  a  description    of    its 
professional health care review program and includes all of  the  information 
specified in R 418.101204.  The workers' compensation  agency  shall  send  a
 copy  of  the certification  of  the  carrier's  review  program   to    the 
carrier,  and  to  the service company and review company when appropriate.

  History: 2000 AACS; 2003 AACS; 2005 AACS.


R 418.101207  Types of certification.
  Rule 1207. (1) Certification shall be either unconditional or conditional.
  (2)  The  workers'  compensation  agency    shall    issue    unconditional 
certification for a period of 3 years.
  (3) The agency may issue conditional certification if it   is    determined 
that the carrier or other  entity  does  not  fully  satisfy   the   criteria 
in  R 418.101206(3).  If the carrier or  other  entity  agrees  to  undertake 
corrective action, then conditional certification shall  be  granted  by  the 
agency  for  a maximum period of 1 year.
  (a)  If  the  workers'  compensation  agency  receives   multiple   written 
complaints regarding a  carrier,  or  the  carrier's  review   process,   and 
the  agency determines the complaints are valid, or that the   carrier    has 
not  processed payment for medical services in accord with these rules,  then 
the agency  may issue conditional certification.
  (4)  The  workers'  compensation  agency  may  at  any   time   modify   an 
unconditional certification to a conditional certification if   the    agency 
determines  that the carrier or other entity fails to satisfy  the   criteria 
set  forth  in  R 418.101206(3).
  (5) The carrier shall  have  the  right  to  appeal    the    certification 
decisions under the procedures in these rules.

  History: 2000 AACS; 2005 AACS.


R 418.101208  Renewal of certification.
  Rule 1208. (1) A  carrier  or   other   entity   shall   apply    to    the 
workers' compensation agency for  renewal  of  certification  in  the  manner 
prescribed  by the agency, submitting the application 6 months prior  to  the 
expiration  date on the certification.
  (2) A carrier or other entity shall receive  renewal    of    certification 
upon receipt of an updated description of  its  program  as  specified  in  R 
418.101206.

  History: 2000 AACS; 2005 AACS.


R 418.101209  Carrier's request for reconsideration  of  professional  review 
certification.
  Rule 1209. (1) Within 30 days of the  agency's  denial  of   a    carrier's 
request for professional review program certification,  the   agency    shall 
notify  the carrier of the reasons for denial of the certification and  shall 
notify  the carrier of its right  to   request   reconsideration    of    the 
denial  providing additional information.
  (2) A carrier shall notify the agency, within  30  days  of   receipt    of 
the professional review program certification denial, of   its   disagreement 
with the action of the  agency.   The  carrier's  notice  to  the  agency  of 
disagreement with the agency's denial shall include a detailed statement   of 
the  reasons for the disagreement and shall request reconsideration.

  History: 2000 AACS; 2005 AACS.


R 418.101210  Carrier's request for reconsideration  of  professional  review 
program certification; response.
  Rule 1210. (1)  Within  30  days  of  receipt  of  a   carrier's    request 
for reconsideration of professional  review  program    certification,    the 
workers' compensation agency shall notify the carrier of the  actions   taken 
and  shall furnish a detailed statement of the reasons for the action taken.
  (2) The agency shall furnish the carrier with  an   appeal    form.     The 
appeal form shall include an explanation of the appeal process.
  (3) If a carrier is in disagreement with the action taken by   the   agency 
on its request for reconsideration, then a carrier shall  deliver   or   mail 
its appeal to the agency.
  (4) The workers' compensation agency shall hold a hearing within  30   days 
of the receipt  of  a   carrier's   appeal   of   the    agency's    decision 
regarding certification of the carrier's professional  review  program  under 
section  847 of the act.

  History: 2000 AACS; 2005 AACS.


                PART 13.  PROCESS FOR RESOLVING DIFFERENCES
                BETWEEN CARRIER AND PROVIDER REGARDING BILL

R 418.101301  Carrier's adjustment or rejection of properly submitted bill.
  Rule 1301. (1) If a carrier adjusts or rejects a bill or  a   portion    of 
the bill, then the carrier shall notify  the  provider  within  30  days   of 
the receipt of the bill of the reasons for adjusting or rejecting  the   bill 
or  a portion of the bill and shall notify the provider of  its   right    to 
provide additional information  and  to  request  reconsideration   of    the 
carrier's action.  The carrier shall set forth the  specific   reasons    for 
adjusting  or rejecting a bill or a portion of the bill and request  specific 
information on a form, "Carrier's Explanation of Benefits," prepared  by  the 
agency  pursuant to the reimbursement section of these rules.
  (2) If the provider sends a properly submitted bill  to  a   carrier    and 
the carrier does not respond within 30 days, and if a  provider    sends    a 
second properly submitted bill and does not receive a  response   within   60 
days  from the date the provider supplied the first properly submitted  bill,
 then  the provider may file an application with the agency  for    mediation 
or  hearing.
The provider shall send a completed form entitled "Application for  Mediation 
and Hearing" to the agency and shall send a copy of this form to the carrier.
  (3) The carrier shall notify the employee and the   provider    that    the 
rules prohibit a provider from billing an employee for any amount for  health
 care services provided for the treatment   of   a    covered    work-related 
injury  or illness if that amount is disputed  by  the  carrier   under   its 
utilization review program or if the  amount  is  more  than   the    maximum 
allowable  payment established by these rules.  The carrier shall request the 
employee to notify the carrier if the provider bills the employee.

  History: 2000 AACS; 2005 AACS.


R 418.101302  Provider's request for reconsideration of  properly   submitted 
bill.
  Rule 1302.  A provider may  request  reconsideration  of  its  adjusted  or 
rejected properly submitted bill by a carrier within 60 days of receipt of  a 
notice of an adjusted or rejected  bill  or  a  portion  of  the  bill.   The 
provider's request to the carrier for  reconsideration  of  the  adjusted  or 
rejected  bill  shall  include  a  detailed  statement  of  the  reasons  for 
disagreement with the carrier's adjustment  or  rejection  of  a  bill  or  a 
portion of the bill.

  History: 1998-2000 AACS.


R 418.101303  Provider's  request  for  reconsideration  of  bill;  carrier's 
response to provider's right to appeal.
  Rule 1303. (1) Within  30  days  of  receipt  of  a   provider's    request 
for reconsideration, the carrier shall notify the provider of  the    actions 
taken and provide a detailed  statement  of  the  reasons.    The   carrier's 
notification shall include an explanation of  the  appeal  process   provided 
under  these rules, including the fact that any   requested    administrative 
appeal  hearing shall be conducted by a magistrate of the    department    of 
labor  &  economic growth.
  (2) If a provider disagrees with the action  taken  by  the   carrier    on 
the provider's  request  for  reconsideration,  then  a  provider  may  file
 an application for mediation or hearing with the  department  of   labor   & 
economic growth.  A provider shall send its application for   mediation    or 
hearing  to the agency within 30 days from the date of receipt of a carrier's
 denial  of the provider's request for reconsideration.  The  provider  shall 
send  a  copy of the application to the carrier.
  (3) If, within 60 days of the provider's  request   for    reconsideration, 
the provider does not receive payment for the adjusted  or   rejected    bill 
or  a portion of the bill, or a written detailed statement of   the   reasons 
for  the actions taken by the carrier, then the  provider  may   apply    for 
mediation  or hearing.  The provider shall send the application for mediation 
or hearing to the agency and shall send a copy to the carrier.

  History: 2000 AACS; 2005 AACS.


R 418.101304  Disputes.
  Rule 1304. (1) If a carrier adjusts or rejects a bill or a portion   of   a 
bill under these rules, then  a  notice   given   under    R    418.101301(1) 
creates  an ongoing dispute for the purpose of section 801 of   the   act.
The  time  for making payment of a bill under section 801 of the  act   shall 
not  run  unless the bill is properly submitted according to applicable rules 
and statutes.
  (2) Any dispute that concerns any of the following shall be resolved as  if 
an application for mediation or hearing was filed under section  847  of  the 
act:
  (a) The medical appropriateness of health care or a health care service.
  (b) Utilization of health care or a health care service.
  (c) The need for health care or a health care service.
  (d) Any dispute over the cost of health care or a health care service.
  (3) If the dispute results in the denial  of  medical  treatment   for    a 
worker, or if there is a petition by  an  employer  to  stop  the  employer's 
liability for medical  benefits  previously  ordered,  including  proceedings 
under subrule  (6) of this rule, then the dispute shall receive   the    same 
expedited  treatment accorded to 60-day cases under section 205 of  the  act, 
except that the agency may refer the matter to mediation under section 223 of 
the act.
  (4) A dispute under this rule may  be  submitted  to   arbitration    under 
section 864 of the act.
  (5) A dispute under this rule may be handled  as  a  small   claim    under 
section 841(2) to (10) of the act  if  it  meets  the  requirements  of  that 
section.
  (6) If a carrier is required by the terms  of   an   award    to    provide 
medical benefits, then  the  carrier  shall  continue  to    provide    those 
benefits  until there is a different order by any of the following entities:
  (a) A magistrate.
  (b) The appellate commission.
  (c) The court of appeals.
  (d) The supreme court.
This subrule shall not preclude the use of  the  maximum  allowable  payments 
provided by these rules for the payment of bills by carriers.  If  a  carrier 
files an application to stop or limit its liability under this  subrule,  the 
carrier shall receive the expedited treatment provided for under subrule  (3) 
of this rule.
  (7) If the agency believes that a provider is not  in    compliance    with 
these rules, then the agency may file an application for mediation or hearing 
under this rule.

  History: 2000 AACS; 2005 AACS.


R 418.101305  Resolution of disputes.
  Rule 1305. (1) If a carrier adjusts a fee  or  rejects   a    bill    under 
these rules, then a notice given pursuant to   R   418.101301    creates    a 
continuing dispute for the purpose of section 801 of  the  act.    The   time 
for  making payment of a bill under section 801 of  the  act  shall  not  run 
unless the  bill is properly submitted  according  to  applicable  rules  and 
statutes.
  (2) A magistrate, as provided under sections 315 and 847 of the act  and  R 
408.34 and R 408.35, shall resolve any dispute that  concerns  any   of   the 
following:
  (a) The medical appropriateness of health care or a health care service.
  (b) Utilization of health care or a health care service.
  (c) The need for health care or a health care service.
  (d) Any dispute over the cost of health care or a health care service.
  (3) The agency may participate in any hearings  that    concern    disputes 
when there is an issue that  affects  the   provisions   of    these    rules 
regarding maximum fees, medical appropriateness,  or  utilization  of  health
 care  or health care services.

  History: 2000 AACS; 2005 AACS.


                  PART 14. DATA ACQUISITION

R 418.101401  Annual medical payment report.
  Rule 1401. (1) Payments for  medical   services   received    by    injured 
workers shall be reported to the  workers'  compensation  agency  on  a  form 
prescribed by the agency entitled  "Annual  Medical  Payment  Report."    The 
agency  shall  provide   instruction   to   the    carriers    and    service 
companies   regarding completion of the form.   The  annual  medical  payment 
report  shall  cover  the periods January 1 through  December  31  and  shall 
include all of the  following information:
  (a) The carrier's total number of worker's compensation  cases   and    the 
total medical payments for health care services for those  cases    in    the 
reporting period.
  (b) Medical only cases, defined as those cases where  no   indemnity    was 
paid, and the total medical payments made by the carrier for those cases.
  (c) Wage loss cases, defined as  those  cases  in  which  wage   loss    or 
indemnity was paid, and the total medical payments made by  the  carrier  for 
those cases.
 For the purposes of this annual  medical  payment  report,  once  wage  loss 
benefits are paid, then the case shall always be reported as wage loss.
  (2) The annual medical payment report shall  be  due  in  the   agency   by 
February 28 of each year.  The report  shall  not  include  travel  expenses, 
payments    for   independent     medical      examinations,       vocational 
rehabilitation,    or rehabilitation case management expenses.

  History: 1998-2000 AACS; 2005 AACS.


R 418.101402  Access to workers' compensation case records.
  Rule 1402.  (1)  The  workers'  compensation  agency  shall   have   access 
to necessary workers' compensation health care records,  medical  bills,  and 
other information  concerning  health  care  or   health     service     from 
workers' compensation carriers or providers.
  (2) The agency may review the  records   and   medical   bills    of    any 
provider determined by a carrier to not be in compliance  with   the    rules 
or  to  be requiring unjustified  treatment,  hospitalization,   or    office 
visits.   If  a carrier requests the agency to perform an on-site  review  of 
specific  records and medical bills of a provider, then the   agency    shall 
arrange  a  mutually acceptable visit date with the provider, by telephone or 
in writing, at least 15 working days before  the  visit.   The  agency  shall 
confirm the date  of  the visit in writing not less than 10 working  days  in 
advance.  The agency shall, by that  time,  identify  for  the  provider  the 
records, which the agency  wishes to review.  The records shall remain at the 
provider's place of business.
  (3) The workers' compensation agency  shall  ensure   confidentiality    of 
the individual case records  regarding  health  care  services  provided   to 
any individual.

  History: 1998-2000 AACS; 2005 AACS.


R 418.101404  Access to carrier data for payment of medical claims.
  Rule 1404. (1) The workers' compensation  agency  shall  have   access   to 
payment data from the carrier in the form of the carrier's   explanation   of 
benefits and medical bills for the purposes of data analysis.
  (2) A carrier shall be notified by the  agency  when  information   is   to 
be submitted not less than 60 days before the date required.
  (3) The agency shall  ensure  confidentiality  of  the   billing    records 
provided by the selected carriers.

  History: 1998-2000 AACS; 2005 AACS.


            PART 15 PROCEDURE CODE AND REIMBURSEMENT TABLES


R 418.101501    Tables for health care services and procedures.
  Rule 1501. (1) Procedures that do  not  have  relative   values    assigned 
are referenced in part 15 of these rules and have assigned fees developed  by 
the workers' compensation agency  through  rule  promulgation  and  shall  be 
published as part of these rules.
  (2) The agency  shall  publish  separate  from  these  rules    a    manual 
containing all of the following:
  (a) Procedure codes and relative value units for the  medical,    surgical, 
and radiology services.
  (b) Reference to the ancillary services identified  in   Medicare's   Level 
II codes as adopted by reference in R 418.10107.
  (c) Maximum payment ratios for hospitals.
  (d) A copy of the billing forms and instructions for completion.

  History: 1998-2000 AACS; 2001 AACS; 2003 AACS; 2005 AACS.


R 418.101502   Rescinded.

  History: 2003 AACS; 2005 AACS; 2007 AACS.


R 418.101503   Laboratory procedure codes and maximum allowable payments.
  Rule 1503. (1) The workers'  compensation  agency  shall   determine    the 
maximum allowable payment  for  the  laboratory  procedure  codes,80048-89356 
published in "Physicians' Current Procedural Terminology (CPT®)as adopted  by 
reference  in R 418.10107. The rate shall be determined by  multiplying   the 
Medicare  rate established for the state of Michigan by 110%.
  (2) The pathology procedure  codes  found  in   the   80000    series    of 
procedure codes listed in CPT® as adopted by reference in  R  418.10107  have
 assigned relative values and shall be published by the agency in a  separate 
manual.
  (3)  The   maximum   allowable   payments   for    the    laboratory    and 
pathology procedures shall be published the  Health  Care   Services   Manual 
separate  from these rules.

  History: 2003 AACS; 2005 AACS.



R 418.101504   Rescinded.

   History: 2003 AACS; 2004 AACS; 2006 AACS; 2007 AACS; 2009 MR 12, Eff. July 
7, 2009.