Introduction Pursuant to Mississippi Code Annotated (MCA), section 71-3-15(3)(Rev. 2000), the following Fee Schedule, including Cost Containment and Utilization Management rules and guidelines, is hereby established in order to implement a medical cost containment program. This Fee Schedule, and accompanying rules and guidelines, applies to medical services rendered after the effective date of August 1, 2008, July 1, 2010, and, in the case of inpatient treatment, to services where the discharge date is on or after August 1, 2008 July 1, 2010. This Fee Schedule establishes the maximum level of medical and surgical reimbursement for the treatment of work-related injuries and/or illnesses, which the Mississippi Workers’ Compensation Commission deems to be fair and reasonable. This Fee Schedule shall be used by the Workers’ Compensation Commission, insurance payers, and self- insurers for approving and paying medical charges of physicians, surgeons, and other health care providers for services rendered under the Mississippi Workers’ Compensation Law. This Fee Schedule applies to all medical services provided to injured workers by physicians, and also covers other medical services arranged for by a physician. In practical terms, this means professional services provided by hospital-employed physicians, as well as those physicians practicing independently, are reimbursed under this Fee Schedule. The Commission will require the use of the most current version of the CPT book and HCPCS codes and modifiers in effect at the time services are rendered. All coding, billing and other issues, including disputes, associated with a claim, shall be determined in accordance with the CPT rules and guidelines in effect at the time service is rendered, unless otherwise provided in this Fee Schedule or by the Commission. As used in this Fee Schedule, CPT refers to the American Medical Association’s Current Procedural Terminology codes and nomenclature. CPT is a registered trademark of the American Medical Association. HCPCS is an acronym for the Centers for Medicare and Medicaid Services’ (CMS) Healthcare Common Procedure Coding System and includes codes for procedures, equipment, and supplies not found in the CPT book. However, the inclusion of a service, product or supply in the CPT book or HCPCS book does not necessarily imply coverage, reimbursement or endorsement. I. FORMAT This Fee Schedule is comprised of the following sections: Introduction; General Rules; Billing and Reimbursement Rules; Medical Records Rules; Dispute Resolution Rules; Utilization Review Rules; Rules for Modifiers and Code Exceptions; Pharmacy Rules; Nurse Practitioner and Physician Assistant Rules; Home Health Rules; Skilled Nursing Facility Rules; Evaluation and Management; Anesthesia; Pain Management; Surgery; Radiology; Pathology and Laboratory; Medicine Services; Physical Medicine; Dental; Durable Medical Equipment (DME), Orthotics, Prosthetics and Other HCPCS Codes; Inpatient Hospital Payment Schedule and Rules; and Forms. Each section listed above has specific instructions (rules/guidelines). The Fee Schedule is divided into these sections for structural purposes only. Providers are to use the specific section(s) that contains the procedure(s) they perform or the service(s) they render. In the event a rule/guideline contained in one of the specific service sections conflicts with a general rule/guideline, the specific section rule/guideline will supersede. CPT only © 2007 American Medical Association. All Rights Reserved. 1 Mississippi Workers’ Compensation Medical Fee Schedule Medical Fee Schedule Effective July 1, 2010 This Fee Schedule utilizes Current Procedural Terminology (CPT) codes and guidelines under copyright agreement with the American Medical Association. The descriptions included are full procedure descriptions. A complete list of modifiers is included in a separate section for easy reference. II. SCOPE The Mississippi Workers’ Compensation Medical Fee Schedule does the following: A. Establishes rules/guidelines by which the employer shall furnish, or cause to be furnished, to an employee who suffers a bodily injury or occupational disease covered by the Mississippi Workers’ Compensation Law, reasonable and necessary medical, surgical, and hospital services medicines, supplies or other attendance or treatment as necessary. The employer shall provide to the injured employee such medical or dental surgery, crutches, artificial limbs, eyes, teeth, eyeglasses, hearing apparatus, and other appliances which are reasonable and necessary to treat, cure, and/or relieve the employee from the effects of the injury/illness, in accordance with MCA §71-3-15 (Rev. 2000), as amended. B. Establishes a schedule of maximum reimbursement allowances (MRA) for such treatment, attendance, service, device, apparatus, or medicine. C. Establishes rules/guidelines by which a health care provider shall be paid the lesser of (a) the provider’s total billed charge, or (b) the maximum reimbursement allowance (MRA) established under this Fee Schedule. D. Establishes rules for cost containment to include utilization review of health care and health care services, and provides for the acquisition by an employer/payer, other interested parties, and the Mississippi Workers’ Compensation Commission, of the necessary records, medical bills, and other information concerning any health care or health care service under review. E. Establishes rules for the evaluation of the appropriateness of both the level and quality of health care and health care services provided to injured employees, based upon medically accepted standards. F. Authorizes employers/payers to withhold payment from, or recover payment from, health facilities or health care providers that have made excessive charges or which have provided unjustified and/or unnecessary treatment, hospitalization, or visits. G. Provides for the review by the employer/payer or Commission any health facility or health care provider records and/or medical bills that have been determined not to be in compliance with the schedule of charges established herein. H. Establishes that a health care provider or facility may be required by the employer/payer to explain in writing the medical necessity of health care or health care service that is not usually associated with, is longer and/or more frequent than, the health care or health care service usually accompanying the diagnosis or condition for which the patient is being treated. I. Provides for medical cost containment review and decision responsibility. The rules and definitions hereunder are not intended to supersede or modify the Workers’ Compensation Act, the administrative rules of the Commission, or court decisions interpreting the Act or the Commission’s administrative rules. J. Provides for the monitoring of employer/payers to determine their compliance with the criteria and standards established by this Fee Schedule. K. Establishes deposition/witness fees. L. Establishes fees for medical reports. CPT only © 2007 American Medical Association. All Rights Reserved. Fee data © 2007 Ingenix Introduction Effective July 1, 2010 Medical Fee Schedule M. Provides for uniformity in billing of provider services. N. Establishes rules/guidelines for billing. O. Establishes rules/guidelines for reporting medical claims for service. P. Establishes rules/guidelines for obtaining medical services by out-of-state providers. Q. Establishes rules/guidelines for Utilization Review to include pre-certification, concurrent review, discharge planning and retrospective review. R. Establishes rules for dispute resolution which includes an appeal process for determining disputes which arise under this Fee Schedule. S. Establishes a Peer Review system for determining medical necessity. Peer review is conducted by professional practitioners of the same specialty as the treating medical provider on a particular case. T. Establishes the list of health care professionals who are considered authorized providers to treat employees under the Mississippi Workers’ Compensation Law; and who, by reference in this rule, will be subject to the rules, guidelines and maximum reimbursement limits in this Fee Schedule. U. Establishes financial and other administrative penalties to be levied against payers or providers who fail to comply with the provisions of the Fee Schedule, including but not limited to interest charges for late billing or payment, percentage penalties for late billing or payment, and additional civil penalties for practices deemed unreasonable by the Commission. III. MEDICAL NECESSITY The concept of medical necessity is the foundation of all treatment and reimbursement made under the provision of section 71-3-15, Mississippi Code of 1972, as amended. For reimbursement to be made, services and supplies must meet the definition of “medically necessary.” The sole use of extraneous guidelines, including but not limited to, the Official Disability Guidelines (“ODG”), to determine the appropriateness or extent of treatment or reimbursement is prohibited. Continuation of treatment shall be based on the concept of medical necessity and predicated on objective or appropriate subjective improvements in the patient’s clinical status. Arbitrary limits on treatment or reimbursement based solely on diagnosis or guidelines outside this Schedule are not permitted. A. For the purpose of the Workers’ Compensation Program, any reasonable medical service or supply used to identify or treat a work-related injury/illness which