Fee Schedule - Hme Health Care- 2015 01/01/2015 1600 E Century Ave Ste 1 PO Bx 5585 Bismarck ND 58506-5585 www.wrkfrcesafety.cm
Cpyright Ntice The five character cdes included in the Nrth Dakta Fee Schedule are btained frm the Current Prcedural Terminlgy (CPT), cpyright 2014 by the American Medical Assciatin (AMA). CPT is develped by the AMA as a listing f descriptive terms and five character identifying cdes and mdifiers fr reprting medical services and prcedures perfrmed by physicians. The respnsibility fr the cntent f Nrth Dakta Fee Schedules is with WSI and n endrsement by the AMA is intender r shuld be implied. The AMA disclaims respnsibility fr any cnsequences r liability attributable r related t any use, nnuse r interpretatin f infrmatin cntained in Nrth Dakta Fee Schedule. Fee Schedules, relative value units, cnversin factrs and/r related cmpnents are nt assigned by the AMA, are nt part f CPT and the AMA is nt recmmending their use. The AMA des nt directly r indirectly practice medicine r dispense medical services. The AMA assumes n liability fr data cntained r nt cntained herein. Any use f CPT utside f Nrth Dakta Fee Schedule shuld refer t the mst current Current Prcedural Terminlgy which cntains the cmplete and mst current listing f CPT cdes and descriptive terms. Applicable FARS/DFARS apply. CPT is a registered trademark f the American Medical Assciatin. ADA cdes are cpyright 2014 American Dental Assciatin. All Rights Reserved. Reprduced and distributed under ADA License #2002460. Disclaimer Language The fact that a prcedure r service is assigned a HCPCS cde and a payment rate des nt imply cverage by WSI, but indicates nly hw the prcedure r service may be paid if cvered by the prgram. The existence f a prcedure cde n this list is nt a guarantee that the cde is cvered. CPT nly cpyright 2014 American Medical Assciatin. All rights reserved. Applicable FARS/DFARS Restrictins apply t Gvernment use. 2
Table f Cntents Hme Health Care Payment Methdlgy... 4 Hme Health Cdes G0151-G0164... 6 Hme Health Cdes S9122-S9502... 7 CPT nly cpyright 2014 American Medical Assciatin. All rights reserved. Applicable FARS/DFARS Restrictins apply t Gvernment use. 3
Wrkfrce Safety & Insurance Hme Health Care Payment Methdlgy The WSI Hme Care Fee Schedule prvides fr payment f mst Hme Care services n a per visit amunt. The Hme Care fee schedule amunts are updated each year by the Hme Health Market Basket increase published by CMS in the Federal Register. The increase is applied t the prir year s un-runded amunts and the result is runded t the nearest 50 cents. In additin, certain hme care services that are apprved by the claims analyst are paid at an hurly rate. Generally, the claims analyst will nt apprve an hurly payment unless the expected length f the visits is, n the average, greater than three hurs. The hurly rates will be updated annually based n the same percentage f increase that is applied t thse services that are paid n a per visit basis (i.e., the per visit limits). The amunts n the Hme Care Fee Schedule represent the maximum that will be paid fr the services prvided. WSI pays the lesser f the billed charge r the fee schedule amunt. Many Hme Care services are prvided t claimants by private individuals r entities (i.e., nt licensed as a Hme Health Agency). The claimants in turn prvide WSI with a mnthly billing fr these services. The implementatin f the Hme Care Fee Schedule des nt change WSI plicy that nly certain services may be purchased by a claimant frm a private individual r entity that is nt licensed as a Hme Health Agency. The fllwing is a list f Hme Care services and the WSI plicy n hw they may be prvided and billed. Physical Therapy, Occupatinal Therapy, Speech Language Pathlgy, and Clinical Scial Wrker services must be prvided nly by a Hme Health Agency n a per visit basis. The HCPCS cdes used t bill fr these services reflect either each 15 minutes r per hur. Hwever, these cdes are t be billed as per visit cdes and will be paid n a per visit basis. Skilled nursing services must be prvided by a Hme Health Agency and shuld be primarily prvided n a per visit basis. If the cnditin and needs f a patient are such that he r she is nt a candidate fr a HHA visit payment (primarily because f the length f the visits), the claims analyst may allw the HHA t bill n an hurly basis. The HCPCS cdes used t bill fr these services reflect either each 15 minutes r per hur. Hwever, these cdes are t be billed as per visit cdes and will be paid n a per visit basis. The skilled nursing hurly rate is nly t be used when a patient des nt fit int a traditinal HHA visit. The HCPCS cdes used t bill fr these services reflect each 15 minutes. Hwever, these cdes are t be billed as per visit cdes and will be paid n a per visit basis. As a guideline, the claims analyst shuld nly allw the hurly payment fr these services if the visits are expected t last lnger than 3 hurs, n the average CPT nly cpyright 2014 American Medical Assciatin. All rights reserved. Applicable FARS/DFARS Restrictins apply t Gvernment use. 4
Hme IV services that are apprved by the claims analyst will be paid at the established Hme Health Aide per visit rate. These services are paid in additin t the visit fr that day. Hme IV services must be prvided by a Hme Health Agency. The HCPCS cdes used t bill fr these services reflect per diem. Hwever, these cdes are t be billed as per visit cdes and will be paid n a per visit basis. Hme Health Aide services shuld be primarily prvided by a Hme Health Agency n a per visit basis. If the cnditin and needs f a patient are such that he r she is nt a candidate fr a HHA visit payment (primarily because f the length f the visits), the claims analyst may either 1) allw the HHA t bill fr the services as private duty nursing services n an hurly basis, r 2) allw the claimant t privately cntract fr the nursing services at an hurly rate that is capped by WSI. The HCPCS cdes used t bill fr these services reflect either each 15 minutes r per hur. Hwever, these cdes are t be billed as per visit cdes and will be paid n a per visit basis. The private duty nursing hurly rate is nly t be used when a patient des nt fit int a traditinal HHA visit. The HCPCS cdes used t bill fr these services reflect each 15 minutes. Hwever, these cdes are t be billed as per hur cdes and will be paid n a per hur basis. As a guideline, the claims analyst shuld nly allw the hurly payment fr these services if the visits are expected t last lnger than 3 hurs, n the average. Private duty nursing services (either credentialed r nn-credentialed) may be prvided by either a HHA r by private individuals r entities. These services will be paid at an hurly rate. The HCPCS cdes used t bill fr Credentialed Private duty services reflect each 15 minutes. Hwever, these cdes are t be billed as per hur cdes and will be paid n a per hur basis. Hmemaking services may be prvided by either a HHA r by private individuals r entities. The services must be apprved by the claims analyst and will nly be allwed in special circumstances. These services will be paid at an hurly rate. The payment fr supplies will be packaged int the payment fr the per visit services r the per hur services nted abve. Separately billable Durable Medical Equipment and ther supplies n the WSI DME fee schedule will cntinue t be paid, if submitted n a separate claim frm. CPT nly cpyright 2014 American Medical Assciatin. All rights reserved. Applicable FARS/DFARS Restrictins apply t Gvernment use. 5
WORKFORCE SAFETY & INSURANCE FEE SCHEDULE Hme Health TOTAL FEE ($) Rev Cde HCPCS Cde Hme Health Cdes G0151-G0164 421 G0151* 169.50 421 G0157* 169.50 421 G0159* 169.50 431 G0152* 170.50 431 G0158* 170.50 431 G0160* 170.50 441 G0153* 184.00 441 G0161* 184.00 551 G0154* 155.00 551 G0162* 155.00 551 G0163* 155.00 551 G0164* 155.00 561 G0155* 248.50 571 G0156* 70.00 552 G0154** 61.50 572 G0156** 21.50 582 nne 15.50 589 nne 11.50 * HCPCS cde reflects "each 15 minutes". Billings are t be made n a per visit basis and the payment amunt reflects a per visit amunt. ** HCPCS cde reflects "each 15 minutes". Billings are t be made n an hurly basis and the payment amunt reflects an hurly amunt CPT nly cpyright 2013 American Medical Assciatin. All rights reserved. Applicable FARS/DFARS Restrictins apply t Gvernment use. 6
Rev Cde HCPCS Cde Hme Health Cdes S9122-S9502 571, 572 S9122*** 70.00 551, 552 S9123*** 155.00 551, 552 S9124*** 155.00 431, 432 S9129**** 170.50 421, 422 S9131**** 169.50 570, 571 S9325**** 70.00 570, 571 S9326**** 70.00 570, 571 S9327**** 70.00 570, 571 S9328**** 70.00 570, 571 S9497**** 70.00 570, 571 S9500**** 70.00 570, 571 S9501**** 70.00 570, 571 S9502**** 70.00 570, 571 S9503**** 70.00 570, 571 S9504**** 70.00 *** HCPCS cde reflects "per diem". Billings are t be made n a per visit basis and the payment amunt reflects a per visit amunt **** HCPCS cde reflects "per diem". Billings are t be made n a per visit basis and the payment amunt reflects a per visit amunt CPT nly cpyright 2014 American Medical Assciatin. All rights reserved. Applicable FARS/DFARS Restrictins apply t Gvernment use. 7