(a) Applicability of this rule is as follows:
  (1) This section applies to workers' compensation specific codes, services and programs provided in the Texas workers' compensation system, other than:
    (A) professional medical services described in §134.203 of this title (relating to Medical Fee Guideline for Professional Services);
    (B) prescription drugs or medicine;
    (C) dental services;
    (D) the facility services of a hospital or other health care facility; and
    (E) medical services provided through a workers' compensation health care network certified pursuant to Insurance Code Chapter 1305, except as provided in §134.1 of this title and Insurance Code Chapter 1305.
  (2) This section applies to workers' compensation specific codes, services and programs provided from March 1, 2008 until September 1, 2016.
  (3) For workers' compensation specific codes, services and programs provided between August 1, 2003 and March 1, 2008, §134.202 of this title (relating to Medical Fee Guideline) applies.
  (4) For workers' compensation specific codes, services and programs provided prior to August 1, 2003, §134.201 of this title (relating to Medical Fee Guideline for Medical Treatments and Services Provided under the Texas Workers' Compensation Act) and §134.302 of this title (relating to Dental Fee Guideline) apply.
  (5) Specific provisions contained in the Labor Code or the Texas Department of Insurance, Division of Workers' Compensation (Division) rules, including this chapter, shall take precedence over any conflicting provision adopted or utilized by the Centers for Medicare and Medicaid Services (CMS) in administering the Medicare program. Independent Review Organization (IRO) decisions regarding medical necessity made in accordance with Labor Code §413.031 and §133.308 of this title (relating to MDR by Independent Review Organizations), which are made on a case-by-case basis, take precedence in that case only, over any Division rules and Medicare payment policies.
(b) Payment Policies Relating to coding, billing, and reporting for workers' compensation specific codes, services, and programs are as follows:
  (1) Billing. Health care providers (HCPs) shall bill their usual and customary charges using the most current Level I (CPT codes) and Level II Healthcare Common Procedure Coding System (HCPCS) codes. HCPs shall submit medical bills in accordance with the Labor Code and Division rules.
  (2) Modifiers. Modifying circumstance shall be identified by use of the appropriate modifier following the appropriate Level I (CPT codes) and Level II HCPCS codes. Where HCPCS modifiers apply, carriers shall treat them in accordance with Medicare and Texas Medicaid rules. Additionally, Division-specific modifiers are identified in subsection (n) of this section. When two or more modifiers are applicable to a single HCPCS code, indicate each modifier on the bill.
  (3) Incentive Payments. A 10 percent incentive payment shall be added to the maximum allowable reimbursement (MAR) for services outlined in subsections (d), (e), (g), (i), (j), and (k) of this section that are performed in designated workers' compensation underserved areas in accordance with §134.2 of this title (relating to Incentive Payments for Workers' Compensation Underserved Areas).
(c) When there is a negotiated or contracted amount that complies with Labor Code §413.011, reimbursement shall be the negotiated or contracted amount that applies to the billed services.
(d) When there is no negotiated or contracted amount that complies with §413.011 of the Labor Code, reimbursement shall be the least of the:
  (1) MAR amount;
  (2) health care provider's usual and customary charge, unless directed by Division rule to bill a specific amount; or
  (3) fair and reasonable amount consistent with the standards of §134.1 of this title (relating to Medical Reimbursement).
(e) Case Management Responsibilities by the Treating Doctor is as follows:
  (1) Team conferences and telephone calls shall include coordination with an interdisciplinary team.
    (A) Team members shall not be employees of the treating doctor.
    (B) Team conferences and telephone calls must be outside of an interdisciplinary program. Documentation shall include the purpose and outcome of conferences and telephone calls, and the name and specialty of each individual attending the team conference or engaged in a phone call.
  (2) Team conferences and telephone calls should be triggered by a documented change in the condition of the injured employee and performed for the purpose of coordination of medical treatment and/or return to work for the injured employee.
  (3) Contact with one or more members of the interdisciplinary team more often than once every 30 days shall be limited to the following:
    (A) coordinating with the employer, employee, or an assigned medical or vocational case manager to determine return to work options;
    (B) developing or revising a treatment plan, including any treatment plans required by Division rules;
    (C) altering or clarifying previous instructions; or
    (D) coordinating the care of employees with catastrophic or multiple injuries requiring multiple specialties.
  (4) Case management services require the treating doctor to submit documentation that identifies any HCP that contributes to the case management activity. Case management services shall be billed and reimbursed as follows:
    (A) CPT Code 99361.
      (i) Reimbursement to the treating doctor shall be $113. Modifier "W1" shall be added.
      (ii) Reimbursement to the referral HCP shall be $28 when a HCP contributes to the case management activity.
    (B) CPT Code 99362.
      (i) Reimbursement to the treating doctor shall be $198. Modifier "W1" shall be added.
      (ii) Reimbursement to the referral HCP shall be $50 when a HCP contributes to the case management activity.
    (C) CPT Code 99371.
      (i) Reimbursement to the treating doctor shall be $18. Modifier "W1" shall be added.
      (ii) Reimbursement to a referral HCP contributing to this case management activity shall be $5.
    (D) CPT Code 99372.
      (i) Reimbursement to the treating doctor shall be $46. Modifier "W1" shall be added.
      (ii) Reimbursement to the referral HCP contributing to this case management activity shall be $12.
    (E) CPT Code 99373.
      (i) Reimbursement to the treating doctor shall be $90. Modifier "W1" shall be added.
      (ii) Reimbursement to the referral HCP contributing to this case management action shall be $23.
(f) To determine the MAR amount for home health services provided through a licensed home health agency, the MAR shall be 125 percent of the published Texas Medicaid fee schedule for home health agencies.
(g) The following applies to Functional Capacity Evaluations (FCEs). A maximum of three FCEs for each compensable injury shall be billed and reimbursed. FCEs ordered by the Division shall not count toward the three FCEs allowed for each compensable injury. FCEs shall be billed using CPT Code 97750 with modifier "FC." FCEs shall be reimbursed in accordance with §134.203(c)(1) of this title. Reimbursement shall be for up to a maximum of four hours for the initial test or for a Division ordered test; a maximum of two hours for an interim test; and, a maximum of three hours for the discharge test, unless it is the initial test. Documentation is required. FCEs shall include the following elements:
  (1) A physical examination and neurological evaluation, which include the following:
    (A) appearance (observational and palpation);
    (B) flexibility of the extremity joint or spinal region (usually observational);
    (C) posture and deformities;
    (D) vascular integrity;
    (E) neurological tests to detect sensory deficit;
    (F) myotomal strength to detect gross motor deficit; and
    (G) reflexes to detect neurological reflex symmetry.
  (2) A physical capacity evaluation of the injured area, which includes the following:
    (A) range of motion (quantitative measurements using appropriate devices) of the injured joint or region; and
    (B) strength/endurance (quantitative measures using accurate devices) with comparison to contralateral side or normative database. This testing may include isometric, isokinetic, or isoinertial devices in one or more planes.
  (3) Functional abilities tests, which include the following:
Cont'd...