RULE NO: RULE TITLE
69L-7.501: Florida Workers' Compensation Reimbursement Manual for Hospitals
These changes are based on the record of a public hearing and written submissions and are being made to reflect a settlement agreement between Petitioners in rule challenge litigation and the Department of Financial Services, Respondent, as authorized by the Three-Member Panel pursuant to Section 440.13(12), F.S., at its meeting on June 14, 2007. The changes occur within the sections of the Florida Workers’ Compensation Reimbursement Manual for Hospitals, 2006 Edition, adopted and incorporated by reference as part of this rule, as follows:
Table of Contents
No change.
Section I: Introduction and Purpose of Manual
No change.
Section II: Reimbursement for Federal and Out-of-State-Hospitals
No change.
Section III: Publications Incorporated by Reference
No change.
Section IV: Billing
No change.
Section V: Authorization
No change.
Section VI: Per-Certification of Estimated Length of Stay
No change.
Section VII: Medical Record Maintenance, Release and Copy Charges
No change.
Section VIII: Inpatient Reimbursement and Per Diem Schedule
A. Reported Charges.
No change.
B. Charges for Surgical Implant(s).
All hospitals shall report surgical implant charges according to the National Uniform Billing Committee Official UB-04 Data Specification Manual (National Uniform Billing Manual). For purposes of reimbursement under this Manual, surgical implant charges are those charges identified on the hospital billing form under Revenue Code 278. Reimbursement for surgical implants billed under Revenue Code 278, Surgical implant charges are those charges identified on the hospital billing form under the designated Revenue Code for implants Reimbursement for surgical implants, when charged for inpatient hospital services and supplies, shall be determined separately pursuant to Section IX of this Manual.
C. through D. No change.
E. Stop-Loss Reimbursement.
If the Total Gross Charges After Implant Carve-Out exceeds $51,400.00, the hospital shall be reimbursed seventy-five percent (75%) of the Total Gross Charges After Implant Carve-Out, except as otherwise provided in this Manual.
Subject to any minimum partial payments required by Section XI herein, tThe insurer shall deny, disallow, or adjust payment for charges included in the Total Gross Charges After Implant Carve-Out that do not correspond to the hospital’s Charge Master or are for undocumented or medically unnecessary services or supplies as determined in accordance with Sections XI and XII of this Manual. If any downward adjustment of the Total Gross Charges After Implant Carve- Out, pursuant to Sections XI and XII of this Manual, reduces the Total Gross Charges After Implant Carve-Out to $51,400.00 or less, reimbursement for the Total Gross Charges After Implant Carve-Out shall be pursuant to the applicable Per Diem Schedule.
Section IX: Surgical Implants
A. Cost Formula.
Requests for reimbursement for surgical implant(s) (also referred to as “implantables” by the National Florida Hospital Association Uniform Billing Manual) required during inpatient hospitalization billed under Revenue Code 278 shall not exceed sixty percent shall be fifty percent (50%) over the acquisition invoice cost(s) for the implant(s). Reimbursement for the associated disposable instrumentation required for the implantation of the surgical implant shall be twenty percent (20%) over the acquisition invoice cost, if the associated disposable instrumentation is received with the surgical implant and included on the acquisition invoice. Reimbursement of shipping and handling shall be at cost, if included on the acquisition invoice. This formula shall apply regardless of the amount of the charges reported by the billing hospital on the hospital billing form pursuant to Rule 69L-7.602, F.A.C.
When determining the acquisition invoice cost of the surgical implant(s), the hospital shall subtract any and all price reductions, offsets, discounts, adjustments and/or refunds which accrue to or are factored into the final net cost to the hospital, only if they appear on the acquisition invoice, before increasing the invoice amount by the percentage factors described above. The shipping and handling shall be added after increasing the acquisition invoice amount by the percentage factors above.
Reimbursement pursuant to this Section for surgical implant(s) and associated disposable instrumentation shall be in addition to reimbursement of the Total Gross Charges After Implant Carve-Out pursuant to Section VII of this Manual.
B. Billing and Identification of Surgical Implant Charges.
Hospitals shall identify charges for surgical implant(s) and associated disposable instrumentation on the hospital billing form in the required Form Locator by using the designated revenue code in accordance and in compliance with the guidelines and definition of “Implantables” and “Examples of Other Implants (not all-inclusive)” provided in the National Florida Hospital Association Uniform Billing Manual Incorporated by reference into Rule 69L-7.602, F.A.C.
C. Request for Reimbursement.
No change.
D. Certification of Implant Amount for Reimbursement.
Certification on a bill that the aggregate amount requested for reimbursement for the surgical implant(s) billed under Revenue Code 278 does not exceed in aggregate sixty percent (60%) over the acquisition costs as specified in Section IX: A. may be submitted as follows Certification that the amount requested for reimbursement for the surgical implant(s) and associated disposable instrumentation has been determined in accordance with this Section may be submitted as follows:
1. through 3. No change.
E. Verification of Surgical Implant Costs and Charges.
The hospital’s certification of amounts requested for reimbursement pursuant to this Section, whether written, by prior agreement or electronically via the electronic hospital billing format, and the hospital’s compliance with billing and revenue code specifications in accordance with the National FHA Uniform Billing Manual incorporated by reference into Rule 69L-7.602, F.A.C., shall be subject to verification through audit and medical record review pursuant to Section XII of this Manual.
Upon request by either the Division, Agency or a carrier, or its designee, to conduct an audit or medical record review under this Section, the hospital shall produce a copy to the requester, subject to the provisions of Section XII of this Manual, or make the original documents available for on-site review, or elsewhere by mutual agreement, such medical record(s) and surgical implant invoice purchasing documentation as requested within thirty (30) days of the request.
Neither a request not completion of an audit pursuant to this Section shall toll the time frame for petitioning the Agency for resolution of a reimbursement dispute pursuant to Section 440.13(7), F.S.
Nothing in this Manual is intended to create, alter, diminish, or negate any protections regarding the confidentiality of any cost information produced during the course of such an audit.
Section X: Outpatient Reimbursement
A. Reimbursement Amount.
No change.
B. Scheduled Surgery.
Hospital charges for scheduled outpatient surgery shall be reimbursed sixty 60 percent (60%) of usual and customary charges and shall include all charges for radiology and clinical laboratory services when performed no more than three days prior to the date such surgery is performed on the same date as the surgery.
Hospitals shall make written entry on the hospital billing form to identify whether an outpatient surgery was scheduled or unscheduled, in accordance with Rule 69L-7.602, F.A.C.
Determination of whether outpatient services were surgical or non-surgical shall be pursuant to the CPT® code(s) reported by the hospital on the hospital billing form pursuant to Rule 69L-7.602, F.A.C.
Reimbursement as a surgical procedure applies if the CPT® code reported on the hospital billing form is within the range of 10021-69990, except when the surgical procedure code within the range 10021-69990 is performed for venipuncture or to administer parenteral medication(s), in conjunction with an invasive medical therapeutic or diagnostic procedure such as that requiring placement of a cannula or catheter, or in conjunction wit han invasive radiology or laboratory service that includes injection of diagnostic or therapeutic substance(s), with or without contrast media. For the purpose of determining reimbursement, surgical procedure codes subject to the preceding exceptions shall be considered non-surgical services and subject to the reimbursement provision in A above.
Reimbursement for a scheduled outpatient surgery that results in the admission of the injured employee to the hospital within 24 hours of the scheduled outpatient surgery shall be subject to the reimbursement provisions of Section VII of this manual.
C. through E. No change.
Section XI: Disallowed, Denied and Disputed Charges
No change.
Section XII: Hospital Charge Master and Medical Record Review or Audit
No change.
Appendix A: Definitions
No change.
Appendix B: Rule 69L-7.501,
No change.
The remainder of the reads as previously published.