Forms Incorporated by Reference for Medical Billing, Filing and Reporting

Notice of Change/Withdrawal

 

DEPARTMENT OF FINANCIAL SERVICES

Division of Worker’s Compensation

RULE NO:RULE TITLE:

69L-7.720Forms Incorporated by Reference for Medical Billing, Filing and Reporting

NOTICE OF CHANGE

Notice is hereby given that the following changes have been made to the proposed rulerulesrule chapter in accordance with subparagraph 120.54(3)(d)1., F.S., published in Volume 41, No. 91, May 11, 2015, issue of the Florida Administrative Register, and subsequently amended by a notice of change published in Vol. 41, No. 216, November 5, 2015, issue of the Florida Administrative Register.

 

The changes to the proposed rule are based on the record of a public hearing conducted on May 11, 2015, and include certain technical changes.

 

SUMMARY OF CHANGES:

 

The form completion instructions for the DFS-F5-DWC-90 (UB-04) located in the headers of incorporated forms are changed as follows:

 

Edition (“2015”) and copyright (“July 2014”) date references to the NATIONAL UNIFORM BILLING COMMITTEE OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL (UB-04 MANUAL) are deleted from the form completion instructions headers.

 

Language requiring insurer/claim administrator information to be entered in the blank area at the top of the DFS-F5-DWC-90 (UB-04) billing form is deleted.

 

In addition to the above-referenced changes, the form completion instructions in the header of Form DFS-F5-DWC-90-B (Completion Instructions for Ambulatory Surgical Centers) are revised to clarify that compliance with the UB-04 Manual is required unless modified by the aforementioned form completion instructions. Reflecting the above changes, the form completion instructions in the header of Form DFS-F5-DWC-90-B are changed to read as follows:

 

“AMBULATORY SURGICAL CENTER (ASC) PROVIDERS SHALL COMPLETE THE DFS-F5-DWC-90 (UB-04) ACCORDING TO THE NATIONAL UNIFORM BILLING COMMITTEE OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL (UB-04 MANUAL), AS INCORPORATED BY REFERNCE IN RULE 69L-8.072, F.A.C., UNLESS MODIFIED BY THESE INSTRUCTIONS.”

 

Information located in the Form DFS-F5-DWC-90-B field numbers listed below are modified as follows:

 

Field Numbers 3a and 3b: Comments are modified to read “Assigned by ASC.”

Field Number 10: Comment regarding date information is modified to require a MMDDYYYY format.

Field Number 42: Comments are modified to read as follows: “Pursuant to the UB-04 Manual.”

Field Number 44: Comment modified to read as follows: “Pursuant to the UB-04 Manual and Rule 69L-7.100, F.A.C., CPT or workers’ compensation unique code(s) and modifier(s) are required for all applicable Revenue Codes.”

 

Field Number 47: Comments modified to read as follows: “Total of billed charges. Total at the bottom of field number 47 is a summation of all the individual charges for each line item.”

Field Number 62: Field Status is modified to indicate “NOT REQUIRED.” Comment language is removed.

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