WSR 16-05-086 PROPOSED RULES DEPARTMENT OF LABOR AND INDUSTRIES [Filed February 16, 2016, 3:19 p.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 16-01-165.
Title of Rule and Other Identifying Information: Medical aid rules, conversion factors and maximum daily fees, WAC 296-20-135, 296-23-220, and 296-23-230.
Hearing Location(s): Department of Labor and Industries, Room S117, 7273 Linderson Way S.W., Tumwater, WA 98501, on March 23, 2016, at 1:00 p.m.
Date of Intended Adoption: May 3, 2016.
Submit Written Comments to: Emily Stinson, P.O. Box 44322, Olympia, WA 98504-4322, e-mail Emily.Stinson@LNI.wa.gov, fax (360) 902-4249, by 5 p.m. on March 29, 2016.
Assistance for Persons with Disabilities: Contact Emily Stinson by March 16, 2016, TTY (360) 902-6687 or fax (360) 902-4249.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: (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.
WAC 296-20-135(3), increase the RBRVS conversion factor from$59.98 to $60.91. Increase the anesthesia conversion factor from $3.38 to $3.41.
WAC 296-23-220 and 296-23-230, increase the maximum daily rate for physical and occupational therapy services from $124.44 to $125.68.
Reasons Supporting Proposal: This rule will provide medical aid updates regarding rate setting for most professional health care services for injured workers.
Statute Being Implemented: RCW 51.36.080.
Rule is not necessitated by federal law, federal or state court decision.
Agency Comments or Recommendations, if any, as to Statutory Language, Implementation, Enforcement, and Fiscal Matters: (1) Increasing the conversion factor used to calculate maximum payment for RBRVS and anesthesia services; and (2) increasing the maximum daily payment for physical and occupational therapy services.
Name of Proponent: Department of labor and industries, governmental.
Name of Agency Personnel Responsible for Drafting: Emily Stinson, Tumwater, Washington, (360) 902-5974; Implementation and Enforcement: Vickie Kennedy, Assistant Director, Tumwater, Washington, (360) 902-4997.
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).
A cost-benefit analysis is not required under RCW 34.05.328. 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).
February 16, 2016
Joel Sacks
Director
AMENDATORY SECTION (Amending WSR 15-09-120, filed 4/21/15, effective 7/1/15)
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 $((59.98)) 61.52. 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 $((3.38)) 3.41 per minute, which is equivalent to $((50.70)) 51.15 per 15 minutes. The base units and payment policies can be found in the fee schedules.
AMENDATORY SECTION (Amending WSR 15-09-120, filed 4/21/15, effective 7/1/15)
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, a physical therapist assistant serving under the direction of a licensed physical therapist as required in RCW 18.74.180 (3)(a), or a licensed athletic trainer serving under the direction of a licensed physical therapist as required in RCW 18.250.010 (4)(a)(v). In addition, physician assistants may order physical therapy under these rules for the attending doctor. 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 $((124.44)) 125.68 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.
AMENDATORY SECTION (Amending WSR 15-09-120, filed 4/21/15, effective 7/1/15)
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. In addition, physician assistants may order occupational therapy under these rules for the attending doctor. 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 or by the physician assistant.
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 $((124.44)) 125.68 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.
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