2019 MWCC Medical Fee Schedule Update and the Changes You Need to Know

Important Dates Proposed Fee Schedule filed with the Secretary of State: March 29, 2019 Public Hearing: April 18, 2019 at 10 am in Hearing Room C Effective Date pending no substantive changes: May 1, 2019.

Purchase Information Preorder the Fee Schedule beginning April 1, 2019 orders.fairhealth.org Hard Copy Binder = $225 PDF= $190 + $60 per additional user PDF + Excel = $400 + $65 per additional use

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Update in MWCC Communication The MWCC will create a listserv email for stakeholders concerning Fee Schedule Issues/Changes To sign up: go to www.mwcc.ms.gov and register today! If you have already registered as an MWCC user, please check your information. Providers should register under “Other”

Skilled Nursing This section has been incorporated to the Facility Section

Billing and Reimbursement 20 Day/30 Day Rule conflict has been remedied. The Fee Schedule and MWCC Rule 1.9 both reflect that within twenty (20) days of each date of service all treating and examining physicians must file a CMS 1500 with the Commission and the E/C. One (1) year limit to reconsideration AND refunds from the date of service from the Provider.

Authorization and Pre-Certification Utilization Review Rules section has been removed from the Fee Schedule for clarification. WHY DID THE MWCC CHANGE UR/Authorization/ Pre-certification? Decrease delays in treatment in order to provide faster access to healthcare in hopes of faster return to work. Decrease unnecessary cost of the claims.

Authorization Authorization is ADJUSTER driven decision making to approve or deny medical services. Examples: physical therapy, repeat MRI, TENS units, home health, orthotics or prosthetics, etc. An Adjuster can still chose to send a medical service to pre-certification, but it is not mandatory. If pre-cert is not used to determine authorization and the medical service is denied by the adjuster, an evidence based practice standard must be used and cited giving the reason for denial. Any adverse determination must have concurrence of a physician of the same specialty and licensure to practice in MS. The payer may override the adverse determination of a pre-certification/utilization review agent and authorize the medical service.

Pre-Certification Pre-Certification is a determination of medical necessity of treatment by a MEDICAL provider. Three (3) Mandatory Requirements: All Admissions to Inpatient Facilities of any type. All Surgical Procedures—inpatient or outpatient Pain Management Procedures

Authorization and Pre-Certification Provider will fill out the MWCC A/P Form and attach relevant medical records. Adjuster will fill out the bottom section and return to the Provider, if indicated. MWCC A/P Form is a cover sheet that streamlines the process. Failure to attach the MWCC A/P Form may not be used as a basis for denial of treatment.

Modifiers All modifiers are now located in this one section for a fully compiled list.

Pharmacy Rules Update to Pricing Brand name reimbursement changed to AWP plus a $5 dispensing fee. Generic reimbursement changed to AWP minus 5% plus a $5 dispensing fee. Other Special Pricing: All creams, patches, and manufactured topical medications are reimbursed at a standard price per category. Repackaged NDC’s are no longer allowed.

Pharmacy Rules Combined Medications Ex. Vimovo: combo of Aleve and Nexium The entity packaging of two or more products together must be billed as individual line items identified by their original AWP and NDC. This original manufacturer NDC and its associated AWP shall be used to determine ingredient reimbursement. Supplies are considered integral to the package and not separately reimbursed.

Pharmacy Rules What happens if a drug formulary is adopted? In the event that the MWCC implements a drug formulary, the Formulary and any subsequent pharmacy fee schedule will govern and supersede the rules in this Fee Schedule where they conflict.

Evaluation and Management DOCUMENTATION MUST BE PATIENT SPECIFIC, PERTAIN DIRECTLY TO THE CURRENT VISIT AND SUPPORT THE EVALUATION AND MANAGEMENT SERVICES PROVIDED FOR THE INJURED WORKER. INFORMATION COPIED DIRECTLY FROM PRIOR RECORDS WITHOUT CHANGE IS NOT CONSIDERED CURRENT NOR COUNTED.

Pain Management The content has been separated into billing information and criteria. Bilateral and multiple procedure will be paid at 25%. Re-pricing of spinal cord stimulators. MWCC Opioid Guidelines Handout REIMBURSEMENT FOR PAIN MANAGEMENT INJECTIONS

Surgery J1 Codes APC Values for knee, hip, and shoulder replacements

Lab and Pathology Drug Screens Mississippi Specific Codes Validation Presumptive Definitive Mississippi Specific Codes 0430M 0431M

Medicine New Psychology Codes Psychological Testing Neuropsychological Testing

Therapeutic Services New language All services performed by healthcare professionals must meet the standards of practice and requirements as established by the applicable state licensing and regulatory agency that governs licensure of the provider in the state of Mississippi.

Facility Payment Schedule and Rules DRG paid only up to billed charges Critical Access Hospitals

HCPCS Values were given to some non-covered CMS items