A client of DaisyBill recently brought to our attention another poor Independent Bill Review (IBR) by Maximus Federal Services, the entity the California Division of Workers’ Compensation (DWC) contracts to review and decide on IBR requests submitted by providers. The IBR decision concerns procedure code 0232T for platelet-rich plasma injection. In the past, Maximus decided in favor of the doctor in the majority of IBRs submitted for 0232T. However, recently Maximus inexplicably changed the criteria for reviewing 0232T, and started to issue denials of payment for this procedure code.

That’s because Maximus is making these important payment decisions without referencing California Labor Code, California Code of Regulations, or administrative rules.

The Trouble With Procedure Code 0232T

CPT 0232T is inherently complex. The code encompasses several procedures related to plasma-rich platelet injections, including image guidance, bloodwork, and plasma harvesting, among others.

0232T is a Level III HCPCS code, temporary by definition (hence the “T”). A Level III designation is typically reserved for emerging or experimental procedures. Once the procedure and its costs are more firmly established by precedent, the Current Procedural Terminology (CPT) typically replaces a Level III code with a more clearly defined Level I CPT code.

In the meantime, this temporary status begs the question: how is reimbursement determined? Medicare assigns this procedure code a Status Code C. As defined by the California Code of Regulations (CCR), Status Code C means that providers are to bill the procedure “by report” (BR). Providers must establish the reimbursement amount and justify the charge in a detailed (non-reimbursable) report.

Needless to say, this leaves the dollar value of a platelet-rich plasma injection open to some interpretation— with interpretations often differing between providers and claims administrators.

Doctors and 0232T

Since reimbursement for procedure code 0232T is established by report, it’s up to a doctor to argue for what they consider to be proper reimbursement. This requires the doctor to devote their own time and resources— already taxed by the complexities of work comp— to shoring up their bills for this procedure. As required by CCR § 9789.12.4, the doctor’s report must establish “in as much detail as possible”:

• The necessity of the procedure
• The length of the procedure
• The equipment and expertise required

While the CCR imposes clear demands on providers for justifying that they should be paid for these “By Report” procedure codes, it offers only a suggestion for determining the actual amount of reimbursement. Per CCR § 9789.12.4(c):

“...consideration may be given to the value assigned to a comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of resources required for the procedure performed such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”

With only a vague notion of basing payment on comparisons and analogies, the door is wide open for claims administrators to question requested reimbursements.

Maximus and 0232T

This is where Maximus, in its decidedly finite wisdom, comes in. Too often, Maximus randomly applies its own standards for determining reimbursement for these “By Report” procedures. Below is an example of an IBR decision by Maximus in which Maximus based its IBR decisions on their own criteria, rather than criteria suggested by CCR § 9789.12.4. Maximus stated:

 “0232T reflects Zero Value under OMFS. As such, 0232T is a By Report Code and reimbursement is based on one of the following: contractual agreement, documented paid cost, or the Providers [sic] usual and customary fee.”

While this Maximus language smacks of legalese, it is not based on any California Labor Code, CCR, or administrative rule. This reimbursement criteria is purely a creation of the Maximus IBR panel. How Maximus determined that reimbursement for “By Report’ procedures is based on either “documented paid costs” or “Providers [sic] usual and customary fee” is a mystery to us.

Even worse, in some cases Maximus ruled against the doctor because the doctor failed to establish their “usual and customary fee” when submitting a Request For Authorization (RFA) for 0232T. In fact, of the eight recent decisions against providers, seven of these decisions specifically cite the doctor’s failure to use the RFA to establish a reimbursement amount.

This is not consistent with the established purpose of an RFA. Per § 9792.6, the function of an RFA is for a provider to request authorization from the claims administrator’s utilization review for proposed medical treatment:

“(q) “Request for authorization” means a written confirmation of an oral request for a specific course of proposed medical treatment pursuant to Labor Code section 4610(h) or a written request for a specific course of proposed medical treatment.”

Utilization review determines whether to approve, modify or deny the doctor’s proposed treatment based on medical necessity, not cost. As  CCR § 9792.6 clearly explains, the purpose of utilization review is not for bill review or to ensure billing accuracy:

(u) “Utilization review process” means utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, or deny, based in whole or in part on medical necessity to cure or relieve, treatment recommendations by physicians, as defined in Labor Code section 3209.3, prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Labor Code section 4600. Utilization review does not include determinations of the work-relatedness of injury or disease, or bill review for the purpose of determining whether the medical services were accurately billed.

As CCR § 9792.6 says, authorization amounts to assurance of “appropriate reimbursement.” To determine what reimbursement is “appropriate,” for a BR code, the provider spends their own time and resources preparing a detailed report. Yet Maximus insists, for reasons unknown, that payers are justified in denying payment when the price tag for 0232T is not included in the RFA.

An RFA must identify the employee, the provider, and the specific course of treatment being proposed. It must be accompanied by documentation substantiating the need for said treatment. But no RFA regulations require the reimbursement amount to be specified.

Maximus is improvising, and improvising clumsily.

Our Client’s Conundrum

The most recent outrage is the completely incoherent decision Maximus made against our client. Maximus upheld a denial of payment for 0232T on utterly erroneous grounds, once again because the provider did not specify a dollar figure for the procedure in the RFA. Not only was the ruling yet another example of Maximus’ reliance on this very flawed argument, it also included self-contradictory language that further shook our confidence in Maximus.

Our client obtained authorization for 0232T via utilization review, established their fee in the Original Bill, and justified the service by report, as required. When the claims administrator denied the reimbursement charged, our client followed proper protocol for the Second Review appeal and subsequent IBR appeal. Yet Maximus ruled in favor of the payer. As in other cases, Maximus (incorrectly) argued that the provider failed to establish their “usual and customary fee” when requesting authorization, despite the provider being under no legal obligation to do so.

The cherry on this failure-cake of an IBR was the baffling statement by the reviewer that “additional reimbursement is indicated not indicated for 0232T.”

You read that right: “indicated not indicated.”

Even without the usual baseless claims regarding “usual and customary fees” and RFAs, this “Schrödinger’s indication” renders the decision impossible to take seriously— or even make sense of. Whether it’s the result of a typical failure of logic or an amateurish failure of grammar, Maximus can’t possibly expect the provider to accept it.

Our client is appealing this decision, and rightly so. Any provider that finds themselves denied correct reimbursement, even by Maximus, is doing the workers’ comp field a service by standing up for their rights. Perhaps if enough providers do so, Maximus will strive to better represent California Labor Code, regulations and rules.

DaisyBill offers all the tools a provider needs to bill compliantly and effectively, despite rulings like this one. Our Billing Software features fast, convenient RFA templates, plus internal tracking that alerts providers when a response from the claims administrator is due. Schedule a free demonstration, and make work comp easier for your office:

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