WSR 04-05-075

PROPOSED RULES

DEPARTMENT OF

LABOR AND INDUSTRIES

[ Filed February 17, 2004, 1:51 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 04-01-156.

Title of Rule: Medical aid rules -- Conversion factors and maximum daily fees, WAC 296-20-135, 296-23-220, and 296-23-230.

Purpose: This rule will provide medical aid updates regarding rate setting for most professional health care services for injured workers. These updates also impact rates for health care services provided to crime victims.

Statutory Authority for Adoption: RCW 51.04.020(1) and 51.04.030.

Statute Being Implemented: RCW 51.36.080.

Summary: The purpose of the rule is to update the department's payment rates for health care services by:

(1) Changing the conversion factor used to calculate payment levels for services payable through the resource based relative value scale (RBRVS) fee schedule;

(2) Changing the conversion factor used to calculate payment for anesthesia services; and

(3) Increasing the maximum daily payment for physical and occupational therapy.

Reasons Supporting Proposal: This rule will provide medical aid updates regarding rate setting for most professional health care services for injured workers. These updates also impact rates for health care services provided to crime victims.

Name of Agency Personnel Responsible for Drafting: Tom Davis, Tumwater, Washington, (360) 902-6687; Implementation and Enforcement: Robert Malooly, Assistant Director, Tumwater, Washington, (360) 902-4209.

Name of Proponent: Department of Labor and Industries, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: The purpose of the rule is to update the department's payment rates for health care services by:

(1) Increasing the conversion factors used to calculate maximum payment for services paid with the resource based relative value scale (RBRVS) fee schedule;

(2) Increasing the conversion factor used to calculate maximum payment for anesthesia services; and

(3) Increasing the maximum daily payment for physical and occupational therapy services.

The conversion factor updates are made in accordance with WAC 296-20-132, Determination of conversion factor adjustments. The anticipated effect of this rule change is to allow crime victims continued access to health care services.

Proposal Changes the Following Existing Rules: WAC 296-20-135(2), increase the RBRVS conversion factor from $50.58 to $50.63;

WAC 296-20-135(3), increase the anesthesia conversion factor from $2.80 to $2.81; and

WAC 296-23-220 and 296-23-230, increase the maximum daily rate for physical and occupational therapy services from $103.65 to $104.12.

No small business economic impact statement has been prepared under chapter 19.85 RCW. This rule adoption is exempt under RCW 34.05.328 (5)(b)(vi) and 19.85.025(3).

RCW 34.05.328 does not apply to this rule adoption. RCW 34.05.328 does not apply because the content of this rule is explicitly dictated by statute and fits within the exceptions listed in RCW 34.05.328 (5)(b)(vi).

Hearing Location: Department of Labor and Industries, 7273 Linderson Way S.W., Tumwater, WA 98501, on March 23, 2004, at 1:00 p.m.

Assistance for Persons with Disabilities: Contact Tom Davis by March 16, 2004, TDD 1-800-833-6388 or fax (360) 902-4249 or e-mail dato235@lni.wa.gov.

Submit Written Comments to: Tom Davis, P.O. Box 4322, Olympia, WA 98501-4322, phone (360) 902-6687, fax (360) 902-4249, e-mail dato235@lni.wa.gov, by March 30, 2004.

Date of Intended Adoption: April 20, 2004.

February 17, 2004

Paul Trause

Director

OTS-6956.1


AMENDATORY SECTION(Amending WSR 03-14-043, filed 6/24/03, effective 8/1/03)

WAC 296-20-135   Conversion factors.   (1) Conversion factors are used to calculate payment levels for services reimbursed under the Washington resource based relative value scale (RBRVS), and for anesthesia services payable with base and time units.

(2) Washington RBRVS services have a conversion factor of (($50.58)) $50.63. The fee schedules list the reimbursement levels for these services.

(3) Anesthesia services that are paid with base and time units have a conversion factor of (($2.80)) $2.81 per minute, which is equivalent to (($42.00)) $42.15 per 15 minutes. The base units and payment policies can be found in the fee schedules.

[Statutory Authority: RCW 51.04.020(1) and 51.04.030. 03-14-043, 296-20-135, filed 6/24/03, effective 8/1/03; 02-10-129, 296-20-135, filed 5/1/02, effective 7/1/02; 01-10-026, 296-20-135, filed 4/24/01, effective 7/1/01; 00-09-077, 296-20-135, filed 4/18/00, effective 7/1/00. Statutory Authority: RCW 51.04.020(4) and 51.04.030. 99-10-043, 296-20-135, filed 4/30/99, effective 7/1/99; 98-09-125, 296-20-135, filed 4/22/98, effective 7/1/98; 97-10-017, 296-20-135, filed 4/28/97, effective 7/1/97. Statutory Authority: RCW 51.04.020 and 51.04.030. 96-19-060. 296-20-135, filed 9/16/96, effective 10/17/96; 96-10-086, 296-20-135, filed 5/1/96, effective 7/1/96; 95-17-001 296-20-135, filed 8/2/95, effective 10/1/95; 95-05-072, 296-20-135, filed 2/15/95, effective 3/18/95. Statutory Authority: RCW 51.04.020, 51.04.030 and 1993 c 159. 94-02-045 and 94-03-008, 296-20-135, filed 12/30/93 and 1/6/94, effective 3/1/94; 93-16-072, 296-20-135, filed 8/1/93, effective 9/1/93. Statutory Authority: RCW 51.04.020(4) and 51.04.030. 91-02-063, 296-20-135, filed 12/28/90, effective 1/28/91; 88-24-011 (Order 88-28), 296-20-135, filed 12/1/88, effective 1/1/89; 87-03-004 (Order 86-45), 296-20-135, filed 1/8/87; 83-24-016 (Order 83-35), 296-20-135, filed 11/30/83, effective 1/1/84; 82-24-050 (Order 82-39), 296-20-135, filed 11/29/82, effective 7/1/83. Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). 81-24-041 (Order 81-28), 296-20-135, filed 11/30/81, effective 1/1/82; 80-18-033 (Order 80-24), 296-20-135, filed 12/1/80, effective 1/1/81. Statutory Authority: RCW 51.04.030 and 51.16.035. 79-12-086 (Order 79-18), 296-20-135, filed 11/30/79, effective 1/1/80; Order 77-27, 296-20-135, filed 11/30/77, effective 1/1/78; Order 76-34, 296-20-135, filed 11/24/76, effective 1/1/77; Order 75-39, 296-20-135, filed 11/28/75, effective 1/1/76; Order 74-7, 296-20-135, filed 1/30/74; Order 71-6, 296-20-135, filed 6/1/71; Order 68-7, 296-20-135, filed 11/27/68, effective 1/1/69.]

OTS-6957.1


AMENDATORY SECTION(Amending WSR 03-14-043, filed 6/24/03, effective 8/1/03)

WAC 296-23-220   Physical therapy rules.   Practitioners should refer to WAC 296-20-010 through 296-20-125 for general information and rules pertaining to the care of workers.

Refer to WAC 296-20-132 and 296-20-135 regarding the use of conversion factors.

All supplies and materials must be billed using HCPCS Level II codes. Refer to chapter 296-21 WAC for additional information. HCPCS codes are listed in the fee schedules.

Refer to chapter 296-20 WAC (WAC 296-20-125) and to the department's billing instructions for additional information.

Physical therapy treatment will be reimbursed only when ordered by the worker's attending doctor and rendered by a licensed physical therapist or a physical therapist assistant serving under the direction of a licensed physical therapist. Doctors rendering physical therapy should refer to WAC 296-21-290.

The department or self-insurer will review the quality and medical necessity of physical therapy services provided to workers. Practitioners should refer to WAC 296-20-01002 for the department's rules regarding medical necessity and to WAC 296-20-024 for the department's rules regarding utilization review and quality assurance.

The department or self-insurer will pay for a maximum of one physical therapy visit per day. When multiple treatments (different billing codes) are performed on one day, the department or self-insurer will pay either the sum of the individual fee maximums, the provider's usual and customary charge, or (($103.65)) $104.12 whichever is less. These limits will not apply to physical therapy that is rendered as part of a physical capacities evaluation, work hardening program, or pain management program, provided a qualified representative of the department or self-insurer has authorized the service.

The department will publish specific billing instructions, utilization review guidelines, and reporting requirements for physical therapists who render care to workers.

Use of diapulse or similar machines on workers is not authorized. See WAC 296-20-03002 for further information.

A physical therapy progress report must be submitted to the attending doctor and the department or the self-insurer following twelve treatment visits or one month, whichever occurs first. Physical therapy treatment beyond initial twelve treatments will be authorized only upon substantiation of improvement in the worker's condition. An outline of the proposed treatment program, the expected restoration goals, and the expected length of treatment will be required.

Physical therapy services rendered in the home and/or places other than the practitioner's usual and customary office, clinic, or business facilities will be allowed only upon prior authorization by the department or self-insurer.

No inpatient physical therapy treatment will be allowed when such treatment constitutes the only or major treatment received by the worker. See WAC 296-20-030 for further information.

The department may discount maximum fees for treatment performed on a group basis in cases where the treatment provided consists of a nonindividualized course of therapy (e.g., pool therapy; group aerobics; and back classes).

Biofeedback treatment may be rendered on doctor's orders only. The extent of biofeedback treatment is limited to those procedures allowed within the scope of practice of a licensed physical therapist. See chapter 296-21 WAC for rules pertaining to conditions authorized and report requirements.

Billing codes and reimbursement levels are listed in the fee schedules.

[Statutory Authority: RCW 51.04.020(1) and 51.04.030. 03-14-043, 296-23-220, filed 6/24/03, effective 8/1/03; 02-10-129, 296-23-220, filed 5/1/02, effective 7/1/02; 01-10-026, 296-23-220, filed 4/24/01, effective 7/1/01; 00-09-077, 296-23-220, filed 4/18/00, effective 7/1/00. Statutory Authority: RCW 51.04.020(4) and 51.04.030. 99-10-043, 296-23-220, filed 4/30/99, effective 7/1/99; 98-09-125, 296-23-220, filed 4/22/98, effective 7/1/98; 97-10-017, 296-23-220, filed 4/28/97, effective 7/1/97; 96-10-086, 296-23-220, filed 5/1/96, effective 7/1/96; 95-05-072, 296-23-220, filed 2/15/95, effective 3/18/95. Statutory Authority: RCW 51.04.020, 51.04.030 and 1993 c 159. 94-02-045, 296-23-220, filed 12/30/93, effective 3/1/94; 93-16-072, 296-23-220, filed 8/1/93, effective 9/1/93.]


AMENDATORY SECTION(Amending WSR 03-14-043, filed 6/24/03, effective 8/1/03)

WAC 296-23-230   Occupational therapy rules.   Practitioners should refer to WAC 296-20-010 through 296-20-125 for general information and rules pertaining to the care of workers.

Refer to WAC 296-20-132 and 296-20-135 for information regarding the conversion factors.

All supplies and materials must be billed using HCPCS Level II codes, refer to the department's billing instructions for additional information.

Occupational therapy treatment will be reimbursed only when ordered by the worker's attending doctor and rendered by a licensed occupational therapist or an occupational therapist assistant serving under the direction of a licensed occupational therapist. Vocational counselors assigned to injured workers by the department or self-insurer may request an occupational therapy evaluation. However, occupational therapy treatment must be ordered by the worker's attending doctor.

An occupational therapy progress report must be submitted to the attending doctor and the department or self-insurer following twelve treatment visits or one month, whichever occurs first. Occupational therapy treatment beyond the initial twelve treatments will be authorized only upon substantiation of improvement in the worker's condition. An outline of the proposed treatment program, the expected restoration goals, and the expected length of treatment will be required.

The department or self-insurer will review the quality and medical necessity of occupational therapy services. Practitioners should refer to WAC 296-20-01002 for the department's definition of medically necessary and to WAC 296-20-024 for the department's rules regarding utilization review and quality assurance.

The department will pay for a maximum of one occupational therapy visit per day. When multiple treatments (different billing codes) are performed on one day, the department or self-insurer will pay either the sum of the individual fee maximums, the provider's usual and customary charge, or (($103.65)) $104.12 whichever is less. These limits will not apply to occupational therapy which is rendered as part of a physical capacities evaluation, work hardening program, or pain management program, provided a qualified representative of the department or self-insurer has authorized the service.

The department will publish specific billing instructions, utilization review guidelines, and reporting requirements for occupational therapists who render care to workers.

Occupational therapy services rendered in the worker's home and/or places other than the practitioner's usual and customary office, clinic, or business facility will be allowed only upon prior authorization by the department or self-insurer.

No inpatient occupational therapy treatment will be allowed when such treatment constitutes the only or major treatment received by the worker. See WAC 296-20-030 for further information.

The department may discount maximum fees for treatment performed on a group basis in cases where the treatment provided consists of a nonindividualized course of therapy (e.g., pool therapy; group aerobics; and back classes).

Billing codes, reimbursement levels, and supporting policies for occupational therapy services are listed in the fee schedules.

[Statutory Authority: RCW 51.04.020(1) and 51.04.030. 03-14-043, 296-23-230, filed 6/24/03, effective 8/1/03; 02-10-129, 296-23-230, filed 5/1/02, effective 7/1/02; 01-10-026, 296-23-230, filed 4/24/01, effective 7/1/01; 00-09-077, 296-23-230, filed 4/18/00, effective 7/1/00. Statutory Authority: RCW 51.04.020(4) and 51.04.030. 99-10-043, 296-23-230, filed 4/30/99, effective 7/1/99; 98-09-125, 296-23-230, filed 4/22/98, effective 7/1/98; 97-10-017, 296-23-230, filed 4/28/97, effective 7/1/97; 96-10-086, 296-23-230, filed 5/1/96, effective 7/1/96; 95-05-072, 296-23-230, filed 2/15/95, effective 3/18/95. Statutory Authority: RCW 51.04.020, 51.04.030 and 1993 c 159. 94-02-045, 296-23-230, filed 12/30/93, effective 3/1/94; 93-16-072, 296-23-230, filed 8/1/93, effective 9/1/93.]

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