Blog: Daisy News

The Centers for Medicare and Medicaid Services (CMS) recently released a Medically Unlikely Edit (MUE) designating acupuncture billing codes 97810 through 97814 non-payable, effective July 1, 2018. However, these codes remain reimbursable under California’s Official Medical Fee Schedule (OMFS) for workers’ comp services.

While National Correct Coding Initiative (NCCI) edits, including MUEs, are incorporated into the OMFS automatically “by reference,” specific OMFS rules designating 97810-97814 reimbursable take precedence.

California’s Division of Workers’ Compensation seeks to update the state’s Medical Treatment Utilization Schedule (MTUS). The DWC wants to align the MTUS with recent and not-so-recent guidelines from the American College of Occupational and Environmental Medicine (ACOEM).

The Division will hold a public hearing regarding the proposed updates on Wednesday, July 18 at 10 am.

California Governor Jerry Brown recently appointed former chorus director Juan Pedro Gaffney to the Workers’ Compensation Appeals Board (WCAB).

Gaffney was a classmate of Governor Brown’s at St. Ignatius College Prep in San Francisco.

A veteran of the San Francisco choir scene, 80-year-old Gaffney brings to the WCAB a lifetime of experience in music education. However, Gaffney is not without regulatory credentials; he served a yearlong stint with the state’s Alcoholic Beverage Control (ABC) department.

First, let’s be clear that providers never have to wait for authorization before providing emergency treatment for an acute medical condition.

Never.

However, the provider must ultimately obtain authorization for all services, even when the injury is time-sensitive or a medical emergency. While the authorization and utilization review (UR) process should never be an obstacle to such treatment, there are mandated procedures and timelines for submitting the official Request for Authorization (RFA).  

California’s Division of Workers’ Compensation (DWC) has many strict requirements as to what constitutes a “complete” bill for the treatment of injured workers. But given the complexity of workers’ comp billing and payment rules, even a bill that’s complete by DWC standards could use a little extra clarification.

That’s why DaisyBill recommends providers include a cover sheet —  like the ones we provide for our billing clients — with all bills.

California’s Division of Workers’ Compensation (DWC) posted update orders to two sections of the Official Medical Fee Schedule (OMFS), both effective July 1, 2018.*

The DWC ordered changes to the Physician and Non-physician Practitioner fee schedule, as well as the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) fee schedule.

The orders affect reimbursement for 5 codes in total, 4 for Physician Services and one for DMEPOS.

Recently, we pointed out that California employers are liable for treatment that precedes the claims administrator’s decision to accept or deny a workers’ comp claim. Before making this liability decision, the employer is always responsible for medically appropriate treatment up to $10,000.

If the employer’s claims administrator denies a bill for treatment when the treatment was provided before the liability decision, the provider should appeal for full payment — even if liability is subsequently denied.

Medical Provider Networks (MPNs) are a drag on California workers’ compensation. Nominally designed to help employers control costs, MPNs rarely achieve more than throwing up obstacles to the treatment of injured workers, and cheating providers out of reimbursement — even for authorized services.

Authorization, of course, is supposed to be final. But when claims administrators grant authorization on the condition that the treating physician be included in the employer’s MPN, they create opportunities to deny payment.