1. ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided by Coventry ® Illinois Medical Bill Reviewer Training Program Introduction and General Guidelines

2. 2 Illinois Regulation Training-Introduction Overview Hi! You probably recognize me. I was the 16 th President and one of the symbols of Illinois. Part I: General Information History Part II: Processing Guidelines Separate Procedures Unlisted Procedures Locator Codes Modifiers Calculating Reimbursements Im here to guide you on a tour of our Workers Compensation fee schedule rules. Together we can become more familiar with the unique aspects of our guidelines.

3. 3 Illinois Regulation Training-Introduction Growth and Change: Illinois Workers Compensation Act 1951: The Illinois Workers Compensation Act established the liability of employers to pay damages for injuries or death received by an employee in the course of employment within Illinois, and outside of Illinois where the contract of employment is made within Illinois. Which workers are covered? Seasonal Part-time Employees of non-profit organizations Employees of unincorporated businesses A single employee of a small business In other words, ALL workers in Illinois are entitled to WC benefits!

4. 4 Illinois Regulation Training-Introduction Growth and Change: Illinois Workers Compensation Act Prior to February 1, 2006 the State of Illinois followed U&C guidelines. The current fee schedule applies to treatment on or after that date.

5. 5 Illinois Regulation Training-Introduction Illinois Workers Compensation Act The Illinois Workers Compensation Act provides for: Benefits are paid by: Medical expenses Wage-loss compensation benefits Death benefits (for work-related deaths paid to dependent survivors) Private insurance companies State Insurance Fund Employers themselves, if self-insured Group Self Insurance

6. 6 Illinois Regulation Training-Introduction Illinois Workers Compensation Injured Workers Labor Unions Insurance Companies Employers Attorneys Service Providers Regulation Agencies The Workers Compensation Program is a large melting pot of many different entities.

7. 7 Illinois Regulation Training-Introduction General Information and Instructions Part I: General Information History Part II: Processing Guidelines Locator Codes Calculating Reimbursements Separate Procedures Procedures Without Unit Value Modifiers Now that you are familiar with the framework of Illinois Workers Comp, lets take a look at some general guidelines & instructions...

8. 8 Illinois Regulation Training-Introduction Locator Codes Illinois is divided into multiple locator codes in the BR4 system – 999, 998, 997, 996, etc. The code is determined by zip code location and impacts both professional and facility bills. Lets take a look… How do I find a Illinois locator code?

9. 9 Illinois Regulation Training-Introduction Locator Codes Step 1: Access Bill Review 4 Reference Materials

10. 10 Illinois Regulation Training-Introduction Locator Codes Step 2: Choose State Reference Guides

11. 11 Illinois Regulation Training-Introduction Locator Codes Step 3: Choose Fee Schedule Location Table

12. 12 Illinois Regulation Training-Introduction Locator Codes Step 4: Find the providers zip code and the effective date of service on the table to locate the providers fee schedule locality.

13. 13 Illinois Regulation Training-Introduction Changing a Billed Procedure Code There is a reluctance with most workers compensation departments and boards to allow payers to change billed codes. This is seen as a possible way to manipulate payment without the providers permission. In Illinois, altering codes is not allowed. Key the procedure as billed.

14. 14 Illinois Regulation Training-Introduction Balance Billing Balance Billing is prohibited by Illinois. A message will print on the EOR when a line reduction has been taken, which will advise the provider that balance billing is prohibited. For all bill types, when the billed charge is greater than the paid amount on a bill where the jurisdiction is Illinois, a message will print on the EOR. The text that prints on the EOR is as follows: "This bill has been reduced. Per Illinois House Bill 2137, Section 8.2 (d), balance billing of the employee is prohibited for costs related to non- disputed services on a compensable injury.

15. 15 Illinois Regulation Training-Introduction Separate Procedures Some listed procedures are carried out as an integral part of a total service, while other procedures are independent of additional services. Procedures that are integral parts of a total service DO NOT warrant separate identification or reimbursement. Separate Procedure: a procedure independent of, and not immediately related to, other services performed, for which reimbursement is ALLOWED. Lets take a look…

16. 16 Illinois Regulation Training-Introduction Separate Procedures For Example: CPT 95851, which codes for a Range of Motion procedure, is an essential part of a follow up visit for a shoulder injury. Therefore, it WOULD NOT warrant separate reimbursement. However, if this procedure were the only service performed, it would be considered a separate procedure and should be ALLOWED.

17. 17 Illinois Regulation Training-Introduction If the necessity of the services has been verified, and the service authorized, additional information may be requested about the procedure, or an online search may be performed. Unlisted Procedures Every effort should be made to identify the service performed with a specific code rather than an unlisted procedure. The unlisted code billed may represent a slightly different version of an established code which would still be appropriate. Procedure codes that do not have a listed value will be recommended for payment at 76% of the billed charge.

18. 18 Illinois Regulation Training-Introduction Unlisted Procedures Every effort should be made to identify the service performed with a specific code rather than an unlisted procedure code. As you know, providers often misuse the unlisted code when a more appropriate code is available. Hmm, which code should I use?

19. 19 Illinois Regulation Training-Introduction Shipping, Handling Charges, Sales Tax There are no state specific reimbursement regulations where shipping, handling, and/or sales tax are mandated or allowed for the state. Key as billed.

20. 20 Illinois Regulation Training-Introduction Dental Services All dental fees shall be paid at 76% of charged amount unless the service is billed under codes listed in this fee schedule (CPT or HCPCS, for example). The CPT or HCPCS code will be reimbursed at the listed value. Key codes and charges as billed.

21. 21 Illinois Regulation Training-Introduction Physical Medicine There are no physical medicine state specific treatment guidelines. Key all physical medicine procedure codes and charges as billed. Payment will be recommended accordingly.

22. 22 Illinois Regulation Training-Introduction Out-of-State Bills: Professional Payment for Illinois claims are based on provider domicile. If the treatment is rendered by an out of state provider, Illinois will pay the greater of: The total fee schedule payment on the bill Or the Illinois fee schedule reimbursement (76% of billed charge).

23. 23 Illinois Regulation Training-Introduction Out-of-State Bills: Facility Out of state facility fees will be paid at 65% of charge for services such as: Prosthetics/orthotics Pacemakers Lens implants Ambulance Investigational devices Certain drugs

24. 24 Illinois Regulation Training-Introduction Modifiers Modifiers indicate that a procedure was altered by additional circumstances, but was not changed from its standard definition. Modifiers may indicate circumstances such as: Only part of the whole procedure was performed. A bilateral procedure was performed. Modifiers will be covered in the context of billed codes.

25. 25 Illinois Regulation Training-Introduction Unique Modifiers that Affect Pricing These Modifiers pay 125% of Fee Schedule Amount: 21 – Prolonged E&M Services 22 – Unusual Procedural Services 23 – Unusual Anesthesia This Modifier pays the lesser of charge or Fee Schedule amount: 24 – Unrelated E&M Service by the same physician during a postoperative period.

26. 26 Illinois Regulation Training-Introduction Calculating Reimbursements Reimbursement rates are tied to values published in the official Illinois fee schedule.

27. 27 Illinois Regulation Training-Introduction Calculating Reimbursements It is important to know that the Bill Review system calculates and applies these reimbursements for you. But, as you can see, knowing how to calculate reimbursements may help you identify errors during bill review or troubleshoot problems when reviewing challenging bills.

28. 28 Illinois Regulation Training-Introduction Summary How reimbursements are calculated. Description of modifiers, separate procedures and unlisted procedures. Illinois Workers Comp Overview. Defined Locator Codes