The proposed rule amendments are intended to incorporate the 2018 editions of the Florida Workers’ Compensation Reimbursement Manual for Ambulatory Surgical Centers and the Florida Workers’ Compensation Health Care Provider Reimbursement Manual. The ...

 

DEPARTMENT OF FINANCIAL SERVICES

Division of Workers’ Compensation

RULE NO.:RULE TITLE:

69L-7.020Florida Workers' Compensation Health Care Provider Reimbursement Manual

69L-7.100Florida Workers' Compensation Reimbursement Manual for Ambulatory Surgical Centers (ASCs)

PURPOSE AND EFFECT: The proposed rule amendments are intended to incorporate the 2018 editions of the Florida Workers’ Compensation Reimbursement Manual for Ambulatory Surgical Centers and the Florida Workers’ Compensation Health Care Provider Reimbursement Manual. The manuals contain the updated lists of Maximum Reimbursable Allowances for various medical services.

SUMMARY: The proposed rule amendments adopt and incorporate by reference the 2018 edition of the Florida Workers’ Compensation Reimbursement Manual for Ambulatory Surgical Centers, and adopt and incorporate by reference the 2018 edition of the Florida Workers’ Compensation Health Care Provider Reimbursement Manual.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION:

The Agency has determined that this will have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has been prepared by the Agency.

The Agency has determined that the proposed rule is expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein:

Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.

RULEMAKING AUTHORITY: 440.13(4), (13), (13)(b); 440.591, FS.

LAW IMPLEMENTED: 440.13(7), (12), (13), (13)(b), FS.

IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: November 27, 2018, 2:00 p.m. – 3:00 p.m. (Rule 7.100) and 3:00 p.m. – 4:00 p.m. (Rule 7.020)

PLACE: Hartman Building, Room 102, 2012 Capital Circle SE, Tallahassee, FL 32301

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 5 days before the workshop/meeting by contacting: Theresa Pugh, telephone: [phone], email: [e-mail].. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Theresa Pugh, Program Administrator, address: Medical Services Section, Division of Workers’ Compensation, 200 East Gaines Street, Tallahassee, FL 32399, telephone: [phone], email: [e-mail].

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

69L-7.020 Florida Workers’ Compensation Health Care Provider Reimbursement Manual.

(1) The Florida Workers’ Compensation Health Care Provider Reimbursement Manual (HCP RM), 2018 2016 Edition, effective July 1, 2019, or upon the rule’s ratifying legislation becoming law, whichever date occurs later, to become effective on July 1, 2017, http://www.flrules.org/Gateway/reference.asp?No=Ref-07685, is incorporated adopted by reference as part of this rule. The manual contains the Maximum Reimbursement Allowances (MRAs) determined by the Three-Member Panel, pursuant to section subsection 440.13(12), F.S., and establishes reimbursement policies, guidelines, codes, and MRAs maximum reimbursement allowances for services and supplies provided by health care providers. Also, the manual includes reimbursement policies and payment methodologies for pharmacists and medical suppliers. The policies and procedures in the HCP RM are in addition to the requirements and responsibilities established throughout Rule Chapter 69L-7, F.A.C., Workers’ Compensation Medical Reimbursement and Utilization Review.

(2) The CPT® 2016 Current Procedural Terminology (CPT®), 2018 Professional Edition, Copyright 2017 2015, American Medical Association; the CDT-2018 2016, Dental Procedure Codes, Copyright 2017 2015, American Dental Association; and, in part, for D codes and for injectable J codes, and for other medical services and supply codes, the “2018 2016 HCPCS Level II Professional Edition,” American Medical Association, Copyright 2018 2016, Elsevier Inc.;, are adopted by reference as part of this rule. When a health care provider performs a procedure or service which is not listed in the Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2016 Edition, incorporated above, the provider must use a code contained in the CPT®-2016, CDT-2016 or HCPCS-2016 as specified in this section. tThe CPT® Assistant, American Medical Association, Copyright 2017; 2015, and the 2018 2016 ICD-10-CM: The Complete Official Codebook, American Medical Association, Copyright 2017 2015, Optum360, LLC, are incorporated also adopted by reference as part of this rule. A copy of the American Medical Association these reference materials may be obtained from the American Medical Association’s website at https://commerce.ama-assn.org/store/. A copy of the CDT reference material may be obtained from the American Dental Association’s website at http://www.ada.org/en/publications/ada-catalog. A copy of the HCPCS Level II reference material may be obtained from the American Medical Association’s website at http://commerce.ama-assn.org/store/.

(3) Posting the preceding copyrighted materials on the Iinternet would constitute a violation of the federal copyright law, so the materials will be made available for public inspection and examination, but may not be copied. The HCP RM and copies of materials incforporated by reference in this rule are available for inspection during normal business hours at the Florida Department of Financial Services, Division of Workers’ Compensation, Bureau of Monitoring and Audit, Hartman Building, 2012 Capital Circle Southeast, Tallahassee, Florida. The preceding non-copyrighted materials may be accessed online via the Department’s Division of Workers’ Compensation website at http://www.myfloridacfo.com/Division/wc/.

Rulemaking Authority 440.13(13)(b), 440.591 FS. Law Implemented 440.13(7), (12), (13)(b) FS. History–New 10-1-82, Amended 3-16-83, 11-6-83, 5-21-85, Formerly 38F-7.20, Amended 4-1-88, 7-20-88, 6-1-91, 4-29-92, 2-18-96, 9-1-97, 12-15-97, 9-17-98, 9-30-01, 7-7-02, Formerly 38F-7.020, 4L-7.020, Amended 12-4-03, 1-1-04, 7-4-04, 5-9-05, 9-4-05, 11-16-06, 10-18-07, 2-4-09, 7-1-16, 7-1-17,              .

Editorial Note: Ratified by Ch. 2016-203, LOF.

 

69L-7.100 Florida Workers’ Compensation Reimbursement Manual for Ambulatory Surgical Centers (ASCs).

(1) The Florida Workers’ Compensation Reimbursement Manual for Ambulatory Surgical Centers (ASC RM), 2018 2015 Edition, effective July 1, 2019, or upon the rule’s ratifying legislation becoming law, whichever date occurs later, effective January 1, 2016, http://www.flrules.org/Gateway/reference.asp?No=Ref-05794 (ASC Reimbursement Manual) is incorporated by reference as part of this rule. The ASC RM Reimbursement Manual contains the Maximum Reimbursement Allowances (MRAs) determined by the Three-Member Panel, pursuant to section subsection 440.13(12), F.S., and establishes reimbursement policies, guidelines, codes, and MRAs maximum reimbursement allowances (MRAs) for items and services provided to an injured worker in connection with a surgical procedure performed in an Ambulatory Surgical Center. The policies and procedures in the ASC RM are in addition to the requirements and responsibilities established throughout Rule Chapter 69L-7, F.A.C., Workers’ Compensation Medical Reimbursement and Utilization Review.

(2) The ASC RM Reimbursement Manual refers to a number of procedure codes and modifiers that are consistent with the Current Procedural Terminology (CPT®), developed and published by the American Medical Association. When a service or procedure is performed that does not have a code listed in the ASC RM Reimbursement Manual, the Ambulatory Surgical Center must shall refer to the Current Procedural Terminology (CPT®), 2018 2015 Professional Edition, Copyright 2017 2014, American Medical Association, which is hereby incorporated by reference as part of this rule. The CPT® Assistant, American Medical Association, Copyright 2017 2015; the 2015 ICD-9-CM Professional Edition for Hospitals, Volumes 1, 2 & 3, American Medical Association, Copyright 2015; the 2015 ICD-9-CM Professional Edition for Physicians, Volumes 1 & 2, American Medical Association, Copyright 2015; the 2018 2015 ICD-10-CM: The Complete Official Draft Codebook, American Medical Association, Copyright 2017, Optum360, LLC 2014 OptumInsight, Inc.; and the 2018 2015 ICD-10-PCS: The Complete Official Draft Codebook, American Medical Association, Copyright 2017, Optum360, LLC, 2014 OptumInsight, Inc. are also incorporated by reference as part of this rule. A copy of these reference materials may be obtained from the American Medical Association’s website at https://commerce.ama-assn.org/store/.

(3) The National Uniform Billing Committee (NUBC), Official UB-04 Data Specifications Manual 2019, as adopted by the NUBC, copyright 2018, American Hospital Association, is incorporated by reference as part of this rule. A copy of this manual can be obtained from the NUBC’s website at http://www.nubc.org/subscriber/.

(4)(3) The CDT 2018 2015, Dental Procedure Codes, Copyright 2017 2014, American Dental Association, is incorporated by reference as part of this rule, for dental D codes. A copy of the CDT reference material may be obtained from the American Dental Association’s website at http://www.ada.org/en/publications/ada-catalog.

(5)(4) Posting the preceding copyrighted materials on the Internet would constitute a violation of the federal copyright law, so the materials will be made available for public inspection and examination, but may not be copied. The ASC RM Reimbursement Manual and copies of materials incorporated by reference in this rule are available for inspection during normal business hours at the Florida Department of Financial Services, Division of Workers’ Compensation, Bureau of Monitoring and Audit, Hartman Building, 2012 Capital Circle Southeast, Document Processing Section, 200 East Gaines Street, Tallahassee, Florida 32399-0311., The preceding non-copyrighted materials may be accessed online or via the Department’s website at http://www.myfloridacfo.com/Division/wc/.

Rulemaking Authority 440.13(4), (13), 440.591 FS. Law Implemented 440.13(7), (12), (13) FS. History–New 8-7-91, Amended 12-31-92, Formerly 38F-7.100, 4L-7.100, Amended 9-4-05, 8-19-07, 11-13-11, 9-28-15, ______.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Theresa Pugh

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: CFO Jimmy Patronis

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: 11/02/2018

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: 07/27/2018