Base value (anesthesia)	Surgical procedures are assigned a base value, e.g., 3 units for a closed procedure on a wrist, 4 units for a closed procedure on a shoulder.  The "2006 Relative Value Guide" lists the base value for each procedure.  The guide is published by the American Society of Anesthesiologists (847/825-5586; cost $25).
Conversion factor	A conversion factor is a dollar amount used to determine the amount of reimbursement for most anesthesia services. The conversion factor is multiplied by time units, base value units, modifier units, and qualifying circumstances units. Calculating the correct fee schedule amount can be determined by consulting the Instructions and Guidelines, ASA Relative Value Guide, and the AMA CPT.
Geozip	A geozip is defined as the first three digits of the zip code in Illinois where the medical treatment was provided.  If you receive medical care in the zip code 60601, for example, the fees would appear in the geozip 606.  Click here to see a list of some of the cities in each Illinois geozip.
Modifier	Modifiers are two-digit numeric or alpha attachments to CPT codes that indicate that a service was altered in some way from the stated CPT description—without actually changing the basic CPT definition. Modifiers can indicate, among other things, that a) the procedure was either professional or technical; b) the procedure was complicated or unusual; c) the procedure was bilateral; d) an adjunctive service was performed; or e) a procedure was performed by more than one person. Some modifiers may affect reimbursement—consult the Instructions and Guidelines for further details.  Note we adopted the AMA CPT modifiers.
POC76	"POC76" means you should pay 76% of the charged amount. By law, the fee schedule was created using actual bills from August 1, 2002 through August 1, 2004. If a code did not exist during that time, or if there were not enough bills with which to calculate a fee, the POC76 was used by default.  All new codes that have been added since the fee schedule was created should be paid at 76% of the charged amount.

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Does the fee schedule cover medical reports? What about copying fees?

A provider may not charge a fee for writing a standard report that is generated in the normal course of treatment (e.g., office visit documentation). If the provider writes a special report that is unusual or outside the standard reporting forms, then an additional fee may be charged.

The fee schedule does not set a fee for the usual code that identifies a special medical report, CPT 99080, nor does it show the default of POC 76. Whenever the fee schedule does not cover a procedure, the usual and customary rate would apply.

The fee schedule does not cover fees for copying medical reports.   The usual and customary rate would apply.

If medical records are subpoenaed, there is no per-page copying fee allowed. The law and rules provide only for mileage and a mandatory $20 fee. (See Section 16 of act; Section 7030.50 of rules; Circuit Courts Act)

Is there a set fee for Section 12 medical exams (also known as independent medical exams)?

No.  An evaluative exam conducted at the employer's request is not considered treatment and is not covered under the fee schedule.

 

Does the fee schedule address missed appointments?

No. The fee schedule only applies to services actually rendered in the treatment of an injured worker.

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Questions Related to Particular Fee Schedule Categories

What facilities are licensed as Ambulatory Surgical Treatment Centers (ASTCs)?

The Illinois Department of Public Health has a list of licensed ASTCS, as well as the ASTC application form and other information on its website. Note that the fee schedule only recognizes ASTCs licensed by the IDPH (see Section 7110.90(h)(1)(A) of the rules).

If anesthesia is given for only part of a 15-minute increment, how should this be billed?

The standard practice is to round up to the next unit. If anesthesia was administered for 7 minutes, for example, you would bill one unit. If anesthesia is administered for 63 minutes, five units would be billed, etc.

If the payer is supposed to pay a percentage of the charged amount for equipment, implants, etc., can it demand a copy of the invoice?

No. The schedule only refers to the charged amount.

The rules do require hospitals to follow their chargemaster, if the items are in the chargemaster. Payers may contact a hospital's financial/contract services staff to check an amount.

 

What do the modifiers NU, RR, and UE mean?

Fees for durable medical equipment vary, depending on whether the equipment is new, old, or rented. According to the HCPCS manual, NU = new equipment; RR = rental; and UE = used equipment.

When an ambulance travels from one geozip to another, which one should count for billing?

The most common and universally accepted practice is to use the geozip of the place where the patient was picked up.

 

Did the IWCC adopt the new MS-DRGs?

Yes, the new MS-DRG hospital inpatient fee schedule is now online. Medicare changed its inpatient coding from the DRG (Diagnosis Related Group) to the MS-DRG (Medical Severity-Diagnosis Related Group) system, and the Commission has adapted to the change.

As provided in our rules, as of June 30, 2009, the inpatient fee schedule is in accordance with the MS-DRG codes. To allow some transition time, the Workers’ Compensation Medical Fee Advisory Board and the Commission ask providers and payers to cooperate and follow a July 31, 2009 effective date.

To view the new inpatient fee schedule, click on the button in the "treatment year" category that says, "New MS-DRG hospital inpatient fee schedule 6/30/09."

For prior dates of treatment, the inpatient fee schedule uses DRGs. Providers and payers should work to translate these bills using the CMS crosswalk, CMS Grouper Version 24.0.

How can I find out which hospitals are designated as Level I & II trauma centers?

Click here for the list.

 

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Payment Questions   

Should we pay medical bills according to our contract or the fee schedule?

If there is a contract for medical services, the contract prevails over the fee schedule.

If there is not a contract, Sections 8(a) and 8.2 require that the employer shall pay the lesser of the provider's actual charges or the amount set by the fee schedule. 

The Workers' Compensation Medical Fee Advisory Board has drafted a statement to clarify the law (Section 8.2(f)) and rules (Section 7110.90(d)) regarding the precedence of an existing contract over the fee schedule.

What can I do if the payer won’t pay me correctly?

There are four options:

1.	The medical provider can charge interest on unpaid amounts.   Payments are due within 60 days of the date the payer receives substantially all the information needed to adjudicate a bill. Unpaid bills accrue interest of 1% per month, under new Section 8.2(d).  Proceed as you would with any other unpaid bill by submitting a statement for accrued interest as part of the overall bill.
2.	The worker can request a hearing regarding unpaid medical bills, and file a petition for penalties and/or attorneys' fees for delay or nonpayment of medical bills.  An employer may have to pay the worker's attorney fees under Section 16; Section 19(k) penalties can run up to 50% of the amount due; Section 19(l) penalties can run up to $30 per day, with a maximum of $10,000. These penalties and fees are payable to the worker.
3.	If the dispute involves issues relating to terms and conditions outlined within the provider agreement, including negotiated discounts between a health care provider and a payer, the Illinois Department of Insurance may be able to help. Contact David Grant, Health Care Coordinator, IDOI, Managed Care Unit, at 217/782-6369 or dave.grant@illinois.gov.
4.	If a person misrepresents the facts for the purpose of denying or obtaining payment, he or she may be guilty of workers' compensation fraud. Section 25.5 provides that fraud is a Class 4 felony. Any person or organization found to have violated this provision is subject to criminal penalties and can be ordered to pay restitution and fines. If you think fraud may be involved, contact Francis "Buzz" Walsh, manager of the WC Fraud unit at the Illinois Division of Insurance (toll-free 877/923-8648 or francis.walsh@illinois.gov).

Is balance billing allowed?

The term "balance billing" refers to an attempt by a medical provider to get an injured worker to pay the unpaid balance of a medical bill. Effective July 20, 2005, there is a prohibition on balance billing.

Section 8.2(e) of the Act provides a provider may seek payment of the actual charges from the employee if the employer notifies a provider that it does not consider the illness or injury to be compensable. If an employer notifies a provider that it will pay only a portion of a bill, the provider may seek payment of the unpaid portion from the employee up to the lesser of the actual charge, the negotiated rate, or the rate in the fee schedule.

If an employee informs the provider that a claim is on file at the Commission, the provider must cease all efforts to collect payment from the employee. Any statute of limitations or statute of repose applicable to the provider's efforts to collect from the employee is tolled from the date that the employee files the application with the Commission until the date that the provider is permitted to resume collection.

While the claim at the Commission is pending, the provider may mail the employee reminders that the employee will be responsible for payment of the bill when the provider is able to resume collection efforts. The provider may request information about the Commission claim and if the employee fails to respond or provide the information within 90 days, the provider is entitled to resume collection efforts and the employee is responsible for payment of the bills. The reminders shall not be provided to any credit agency.

Upon final award or settlement, a provider may resume efforts to collect payment from the employee and the employee shall be responsible for payment of any outstanding bills plus interest awarded. If the service is found compensable, the provider shall not require a payment rate, excluding interest, greater than the lesser of the actual charge or payment level set by the Commission in the fee schedule. The employee is responsible for payment for services found not covered or compensable unless agreed otherwise by the provider and employee. Services not covered or not compensable are not subject to the fee schedule.

Is interest owed if the claim is disputed for valid reasons but later determined to be compensable?

Yes, provided the requirements of Section 8.2(d) are met.

 

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Coding and Billing

How do I pay bills where there are professional and technical components (PC/TC)?

In radiology, pathology and laboratory, and physical medicine, a doctor may bill for the professional component (modifier PC or 26) and a facility may bill for the technical component (modifier TC). A technician may take a x-ray, for example, and a radiologist would read it.

Most of the time, each component is billed separately. When possible, we calculated a fee for each component. If a dollar amount appears under the appropriate PC/TC column, that represents the maximum payment for that component.

If we didn’t have enough data to calculate a fee, by law the schedule defaults to POC76, which means to pay 76% of the charged amount. A bill for either component should be paid at 76%.

For example, the maximum 2008 fee for a chest scan (71275) in geozip 600 is $298.96 for the professional component and $1,195.82 for the technical component. In geozip 609, the default of POC76 is used. If a component is billed separately, it should be paid at 76% of the charged amount. The PC/TC columns, which show that the bill should be split (e.g., 20/80), are relevant only if both components are billed at the same time.

How should the payer handle a bill with incorrect codes?

The Instructions and Guidelines direct users to reference materials incorporated into the fee schedule (e.g., Correct Coding Initiative, AMA’s CPT). To the extent that a medical bill is submitted in a manner inconsistent with these documents, then a bill can be questioned. The payer should contact the provider and try to resolve such issues. If the parties cannot resolve the issue, the employer or worker may file a petition for a hearing before an arbitrator regarding unpaid medical bills.

How are healthcare professionals paid in hospital settings?

All healthcare professionals who perform services in a hospital setting and bill for these services using their own tax ID number on a separate claim form are subject to the Professional Services and/or HCPCS fee schedule. While these services are provided in a hospital setting and not a physician’s office, the application of the fee schedule will be the same as though these services had been provided in the physician’s office. In other words, there is no site-of-service adjustment.

Where professional services are performed in a hospital setting (e.g., a radiologist reading an x-ray, or CRNA services) and billed by the hospital using its tax ID number for these services, then the professional services fee schedule will not apply; rather, the amount paid will be 76% of the charged amount.
 

Must bills be submitted on certain forms?

The rules state that hospital inpatient services should be billed on the UB-04/CMS 1450 claim form. Otherwise, the fee schedule does not dictate the type of billing forms used. (Our act and rules do not require the latest CMS-1500.)  In the interest of facilitating transactions, we do encourage providers to use standard billing forms.

 

How is a bill with pass-through charges handled?

First subtract the pass-through charges (also known as revenue code charges) from the bill, then apply the fee schedule.

If, for example, a bill comes in for $50,000 with $10,000 in pass-through charges, apply the remaining $40,000 to the fee schedule amount, and pay the lesser of the $40,000 or the fee schedule amount. Then pay 65% of the pass-through charges ($6,500 in this example).

 

Should pass-through charges or outlier charges be billed separately from regular services?

You should clearly identify the different charges, but separate bills are not necessary.

How do I apply the modifiers to an out-of-state treatment bill?

First determine if there is a contract. If there is, you follow that.

If there's no contract, determine if the other state has a fee schedule and, if so, determine if it would pay more than 76% of the bill. If it does, you follow that state's fee schedule.

Otherwise, pay 76% of charges, subject to the other instructions and guidelines. First apply the modifiers, then apply the 76%.

For example, if an out-of-state provider (with no contract and no fee schedule in that state) bills $5,000 for a procedure with the modifier 22, which calls for payment at 125%.  Calculation: $5,000 X 125% = $6,250 X 76% = $4,750.

 

Do the fees represent time units?

If the description of a code includes a time increment, then the fee schedule incorporates that time increment. If the description does not contain a time increment, then the fee schedule amount reflects reimbursement for an episode as is generally accepted in Illinois.

Should a medical provider send bills to the employer or the payer?

Throughout the Illinois Workers' Compensation Act, there are many references to the employer where, in practice, the payer (an insurer or third party administrator) assumes responsibility for the employer.  Section 6(b), for example, says the employer shall file accident reports, but the payer usually files them on the employer's behalf. The payer is understood to stand in the shoes of the employer.

Nothing in the new law changes this. A safe policy, therefore, would be for a provider to submit the bill to the payer, when known.  Another option would be to submit the bill to both the employer and the payer.

Can you tell me if I am calculating a bill correctly?

We can provide general answers, as listed on this web page, but we do not have the resources to address individual calculations.

If parties cannot reach agreement over a bill, the worker would request a hearing before an arbitrator regarding unpaid medical bills.

 

Does the attorney have to itemize each medical provider's bill to fit within the fee schedule? For example, instead of listing the charge for an office visit, should he or she list the fee schedule amount?

If bills are not paid and the case goes to arbitration, attorneys should submit the bills as they are, and then, in the proposed decision, identify the amount to be awarded. If the bill is less than the fee schedule amount, the bill is awarded at 100% of the charge. If the bill is more than the fee schedule amount, it is awarded at the fee schedule amount.

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Other 

Does the Illinois fee schedule apply if the worker/employer/medical provider is in another state?

The defining factor is where the worker filed the workers' compensation claim. If the worker filed the claim in Illinois, then Illinois law applies.

For example, if a worker filed a claim in Illinois and received treatment in another state, IL law would apply. IL law provides that out-of-state treatment should be paid at the greater of 76% of the charged amount or that state's fee schedule (if that state has a schedule).

If the worker filed a claim in another state, the law in that state would govern how medical treatment shall be paid.

 

How are the fees adjusted each year?

According to Section 8.2(a) of the Act, on January 1 of each year the IWCC adjusts all the fees by the percentage change in the Consumer Price Index-All Urban Consumers, All Items (1982-84=100) for the 12-month period ending August 31 of the previous year.

Adjustments to Medical Fees
February 1, 2006	4.90%
January 1, 2007	3.80%
January 1, 2008	1.97%
January 1, 2009	5.37%

Note: On 1/1/09, the cost-of-living increase took effect.  The rules that took effect 2/1/09 created three new fee schedules and did not affect the fees in other portions of the fee schedule.

How does the utilization review law affect the process?

Section 8.7 provides that if an employer chooses to conduct utilization review, it must use individuals who are registered with the Illinois Department of Financial and Professional Regulation and who certify compliance with URAC standards for Workers' Compensation Utilization Management (WCUM) or Health Utilization Management (HUM).  Click here to read the IDFPR's UR rules. 

At the IDFPR, Kelly Smith (217/558-2309) coordinates the processing of the UR applications. Click here for a list of approved UR providers.

When making determinations concerning the reasonableness and necessity of medical bills or treatment, the IWCC will consider UR findings along with all other evidence. If an employer follows a WCUM or HUM URAC standard when refusing to pay for or authorize medical treatment, there shall be a rebuttable presumption that the employer should not be assessed penalties under Section 19(k). 

What do I need to know about Workers' Comp Medicare Set-Aside Arrangements?

All parties in a workers' compensation (wc) case are responsible under the Medicare secondary payer laws to protect Medicare's interests when resolving wc cases that include future medical expenses.

Medicare recommends parties draft a Workers' Compensation Medicare Set-aside Arrangement (WCMSA), which allocates a portion of the wc settlement for future medical expenses.

The amount of the set-aside is determined on a case-by-case basis and should be reviewed by the Centers for Medicare and Medicaid Services (CMS), in the following situations:

The claimant is currently a Medicare beneficiary and the total settlement amount is greater than $25,000; or

The claimant has a "reasonable expectation" of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount for future medical expenses and disability/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.

Once the CMS-determined set-aside amount is exhausted and accurately accounted for to CMS, Medicare will pay as primary payer for future Medicare-covered expenses related to the wc injury.

To address the administrative problems that parties face while awaiting set-aside approval, former Chairman Ruth issued a memo directing cases be continued during the approval period.

For more info, go to the Medicare website.

How does HIPAA affect workers' compensation?

The U.S. Department of Health and Human Services, Office of Civil Rights (OCR), administers the Health Insurance Portability and Accountability Act (HIPAA).  It has issued guidelines that indicate that covered providers may disclose health information to workers' compensation insurers, state administrators, employers, and other entities involved in the w.c. system, to the extent disclosure is necessary to comply with, or is required by, state law, or to obtain payment.   

The guidelines include a number of frequently asked questions.  For more information, please contact the U.S. Department of Health and Human Services.