WSR 97-05-076
PROPOSED RULES
DEPARTMENT OF
LABOR AND INDUSTRIES
[Filed February 19, 1997, 11:33 a.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 97-02-097.
Title of Rule: Medical aid rules updates.
Purpose: Update payment rates to medical providers.
Statutory Authority for Adoption: RCW 51.04.020(4) and 51.04.030.
Statute Being Implemented: RCW 51.04.020(4) and 51.04.030.
Summary: (1) Change conversion factor used to calculate reimbursement levels for services payable through the resource based relative value scale (RBRVS) fee schedule; (2) change conversion factor used to calculate reimbursement for anesthesia services; and (3) increase the physical and occupational therapy daily maximum rates.
Reasons Supporting Proposal: Update reimbursement rates.
Name of Agency Personnel Responsible for Drafting: Marilyn Gisser, Tumwater, Washington, (360) 902-6801; Implementation and Enforcement: Joseph G. Bell, Assistant Director, Tumwater, Washington, (360) 902-6696.
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 three changes increase reimbursement to affected medical providers. The purpose and anticipated effect of these proposed changes are to: (1) Change the conversion factor used to calculate maximum reimbursement levels for services reimbursed under the resource based relative values scale (RBRVS) fee schedule. The proposed change adjusts the conversion factor to accommodate changes in the service codes and relative value units which are used to calculate reimbursement levels and grants a 4.22% cost-of-living increase to RBRVS providers; (2) change the conversion factor used to calculate maximum reimbursement for anesthesia services. The proposed change adjusts the conversion factor to accommodate changes in the anesthesia base values that are used to calculate reimbursement and grants a 3.74% cost-of-living increase to anesthesia providers; and (3) apply a 4.22% cost-of-living increase to the maximum daily rate for physical and occupational therapy services.
Proposal Changes the Following Existing Rules: In WAC 296-20-135(2), increase the RBRVS conversion factor from $45.02 to $46.21; in WAC 296-20-135(3), increase the anesthesia conversion factor from $1.87 to $1.94; and in WAC 296-23-220 and 296-23-230, increases the maximum daily rate for physical and occupational therapy services from $73.70 to $76.81.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The Regulatory Fairness Act, chapter 19.85 RCW, requires that a small business economic impact statement be prepared if a proposed rule has the potential of placing a proportionately higher economic impact on small businesses. Since the proposed amendments will result in a average increase in payments to the affected industries, the department is not required to prepare a small business economic impact statement.
Section 201, chapter 403, Laws of 1995, does not apply to this rule adoption. The amendment is not a significant change to existing department policy. It is a routine rate adjustment.
Hearing Location: Department of Labor and Industries, 7273 Linderson Way, Tumwater, WA, on March 27, at 9:00 a.m.
Assistance for Persons with Disabilities: Contact Marilyn Gisser by March 20, 1997, (360) 902-6801.
Submit Written Comments to: Marilyn Gisser, FAX (360) 902-4249, by April 4, 1997.
Date of Intended Adoption: April 28, 1997.
February 19, 1997
Gary Moore
Director
AMENDATORY SECTION (Amending WSR 96-19-060, filed 9/16/96, effective
10/17/96)
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 (($45.02))
$46.21. 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 (($1.87)) $1.94 per minute. The base units and
payment policies can be found in the fee schedules.
(4) Services that do not use a conversion factor to establish
reimbursement levels have dollar values, not relative values listed in
the fee schedules.
[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.]
AMENDATORY SECTION (Amending WSR 96-10-086, filed 5/1/96, effective
7/1/96)
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 (($73.70)) $76.81 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(4) and 51.04.030. 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 96-10-086, filed 5/1/96, effective
7/1/96)
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 (($73.70)) $76.81 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(4) and 51.04.030. 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.]