1. 2019 MWCC Medical Fee Schedule
Update and
the Changes
You Need to Know

3. 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.

4. 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

5. Screen Shot FAIR Health

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

10. Skilled Nursing
This section has been incorporated to the Facility Section

11. 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.

12. 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.

13. 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.

14. 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

15. 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.

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

18. 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.

19. 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.

20. 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.

21. 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.

22. 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

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

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

25. Medicine New Psychology Codes Psychological Testing
Neuropsychological Testing

26. 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.

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

28. HCPCS
Values were given to some non-covered CMS items