Section 134.210 - Medical Fee Guideline for Workers' Compensation Specific Services(a) Specific provisions contained in the Labor Code or division rules, including this chapter, take precedence over any conflicting provision adopted or used by the Centers for Medicare and Medicaid Services (CMS) in administering the Medicare program. Independent review organization decisions on medical necessity made in accordance with Labor Code §413.031 and § 133.308 of this title, which are made on a case-by-case basis, take precedence, in that case only, over any division rules and Medicare payment policies.(b) Payment policies relating to coding, billing, and reporting for workers' compensation specific codes, services, and programs are as follows:(1) Health care providers must bill their usual and customary charges using the most current Level I Current Procedural Terminology (CPT) and Level II Healthcare Common Procedure Coding System (HCPCS) codes. Health care providers must submit medical bills in accordance with the Labor Code and division rules.(2) Modifying circumstance must be identified by use of the appropriate modifier following the appropriate Level I (CPT codes) and Level II HCPCS codes. Where HCPCS modifiers apply, insurance carriers must treat them in accordance with Medicare and Texas Medicaid rules. In addition, division-specific modifiers are identified in subsection (f) of this section. When two or more modifiers apply to a single HCPCS code, indicate each modifier on the bill.(3) A 10% incentive payment must be added to the maximum allowable reimbursement (MAR) for services outlined in §§ 134.220, 134.225, 134.235, 134.240, 134.250, and 134.260 of this title and subsection (d) of this section that are performed in designated workers' compensation underserved areas in accordance with § 134.2 of this title. However, reimbursement for a missed appointment under §134.240 does not qualify for the 10% incentive payment.(4) Fees established in §§ 134.235, 134.240, 134.250, and 134.260 of this title will be: (A) adjusted once by applying the Medicare Economic Index (MEI) percentage adjustment factor for the period 2009 - 2024.(B) adjusted annually by applying the MEI percentage adjustment factor identified in §134.203(c)(2).(C) rounded to whole dollars by dropping amounts under 50 cents and increasing amounts from 50 to 99 cents to the next dollar. For example, $1.39 becomes $1 and $2.50 becomes $3.(D) effective on January 1 of each new calendar year.(c) When there is a negotiated or contracted amount that complies with Labor Code § 413.011, reimbursement must be the negotiated or contracted amount that applies to the billed services.(d) When billing for services in §§134.215, 134.220, 134.225, or 134.230, and there is no negotiated or contracted amount that complies with Labor Code § 413.011, reimbursement must be the least of the:(2) health care provider's usual and customary charge; or(3) fair and reasonable amount consistent with the standards of § 134.1 of this title.(e) For services provided under §§134.235, 134.240, 134.250, or 134.260, health care providers must bill and be reimbursed the MAR.(f) The following division modifiers must be used by health care providers billing professional medical services for correct coding, reporting, billing, and reimbursement of the procedure codes.(1) 25--This modifier must be added to CPT code 99456 when the division ordered the designated doctor to perform an examination of an injured employee with one or more of the diagnoses listed in §127.130(b)(9)(B) - (I) of this title.(2) 52--This modifier must be added to CPT code 99456 when the division ordered the designated doctor to perform an examination of an injured employee, and the injured employee failed to attend the examination.(3) CA, Commission on Accreditation of Rehabilitation Facilities (CARF) accredited programs--This modifier must be used when a health care provider bills for a return-to-work rehabilitation program that is CARF accredited.(4) CP, chronic pain management program--This modifier must be added to CPT code 97799 to indicate chronic pain management program services were performed.(5) FC, functional capacity--This modifier must be added to CPT code 97750 when a functional capacity evaluation is performed.(6) MR, outpatient medical rehabilitation program--This modifier must be added to CPT code 97799 to indicate outpatient medical rehabilitation program services were performed.(7) MI, multiple impairment ratings--This modifier must be added to CPT code 99456 when the designated doctor is required to complete multiple impairment ratings calculations.(8) NM, not at maximum medical improvement (MMI)--This modifier must be added to the appropriate MMI CPT code to indicate that the injured employee has not reached MMI when the purpose of the examination was to determine MMI.(9) VR, review report--This modifier must be added to CPT code 99455 to indicate that the service was the treating doctor's review of reports only.(10) V3, treating doctor evaluation of MMI--This modifier must be added to CPT code 99455 when the office visit level of service is equal to CPT code 99213.(11) V4, treating doctor evaluation of MMI--This modifier must be added to CPT code 99455 when the office visit level of service is equal to CPT code 99214.(12) V5, treating doctor evaluation of MMI--This modifier must be added to CPT code 99455 when the office visit level of service is equal to CPT code 99215.(13) WC, work conditioning--This modifier must be added to CPT codes 97545 and 97546 to indicate work conditioning was performed.(14) WH, work hardening--This modifier must be added to CPT codes 97545 and 97546 to indicate work hardening was performed.(15) W1, case management for treating doctor--This modifier must be added to the appropriate case management billing code activities when performed by the treating doctor.(16) W5, designated doctor examination for impairment or attainment of MMI--This modifier must be added to the appropriate examination code performed by a designated doctor when determining impairment caused by the compensable injury and in attainment of MMI.(17) W6, designated doctor examination for extent--This modifier must be added to the appropriate examination code performed by a designated doctor when determining extent of the injured employee's compensable injury.(18) W7, designated doctor examination for disability--This modifier must be added to the appropriate examination code performed by a designated doctor when determining whether the injured employee's disability is a direct result of the work-related injury.(19) W8, designated doctor examination for return to work--This modifier must be added to the appropriate examination code performed by a designated doctor when determining the ability of the injured employee to return to work.(20) W9, designated doctor examination for other similar issues--This modifier must be added to the appropriate examination code performed by a designated doctor when determining other similar issues.28 Tex. Admin. Code § 134.210
Adopted by Texas Register, Volume 41, Number 27, July 1, 2016, TexReg 4839, eff. 7/7/2016; Amended by Texas Register, Volume 49, Number 10, March 8, 2024, TexReg 1496, eff. 6/1/2024