Health Care Provider Reporting and Billing Responsibilities
69L-7.602 Florida Workers’ Compensation Medical Services Billing, Filing and Reporting Rule.
(4) Health Care Provider Responsibilities.
(a) Bill Submission/Filing and Reporting Requirements.
1. All health care providers are responsible for meeting their obligations, under this rule, regardless of any business arrangement with any entity under which claims are prepared, processed or submitted to the insurer.
2. Each health care provider is responsible for submitting any additional form completion information and supporting documentation requested, in writing, by the insurer at the time of authorization or at the time a reimbursement request is received.
3. Each health care provider shall resubmit a medical claim form or medical bill with insurer requested documentation when the EOBR provides an explanation for disallowance based on the lack of documentation submitted with the medical bill.
4. Insurers and health care providers shall utilize only the Form DFS-F5-DWC-25 for physician reporting of the injured employee’s medical treatment/status. Any other reporting forms may not be used in lieu of or supplemental to the Form DFS-F5-DWC-25. Provider failure to accurately complete and submit the DFS-F5-DWC-25, in accordance with the Form DFS-F5-DWC-25 Completion/Submission Instructions adopted in this rule, may result in the Agency imposing sanctions or penalties pursuant to subsection 440.13(8), F.S. or subsection 440.13(11), F.S.
a. The Form DFS-F5-DWC-25 does not replace physician notes, medical records or Division-required medical reports.
b. All information submitted on physician notes, medical records or Division-required medical reports must be consistent with information documented on the Form DFS-F5-DWC-25.
5. All medical claim form(s) or medical bill(s) related to services rendered for a compensable injury shall be submitted by a health care provider to the insurer, service company/TPA or any entity acting on behalf of the insurer, as a requirement for billing.
6. Medical claim form(s) or medical bill(s) may be electronically filed or submitted via facsimile by a health care provider to the insurer, service company/TPA or any entity acting on behalf of the insurer, provided the insurer agrees.
7. When requested by the insurer, service company/TPA or any entity acting on behalf of the insurer, a health care provider shall send documentation that supports the medical necessity of the specific services rendered and any other required documentation pursuant to paragraph (4)(b) of this rule and the applicable reimbursement manual.
8. Each health care provider is responsible for correcting and resubmitting any billing forms returned by an insurer, service company/TPA or any entity acting on behalf of the insurer pursuant to paragraph (5)(j) of this rule.
9. Each hospital and ambulatory surgical center shall maintain its charge master and shall produce relevant portions when requested for the purpose of verifying its usual charges pursuant to Section 440.13(12)(d), F.S.
(b) Special Billing Requirements.
1. When anesthesia services are billed on a Form DFS-F5-DWC-9, completion of the form must include the CPT® code and the “P” code (physical status modifier), which correspond with the procedure performed, in Field 24D. Anesthesia health care providers shall enter the date of service and the 5-digit qualifying circumstance code, which correspond with the procedure performed, in Field 24D on the next line, if applicable.
2. When an Advanced Registered Nurse Practitioner (ARNP) provides services as a Certified Registered Nurse Anesthetist, the ARNP shall bill on a Form DFS-F5-DWC-9 for the services rendered and enter his/her Florida Department of Health ARNP license number in Field 33b, regardless of the employment arrangement under which the services were rendered, or the party submitting the bill.
3. Regardless of the employment arrangement under which the services are rendered or the party submitting the bill, the following health care providers, who render direct billable services for which reimbursement is sought from an insurer, service company/TPA or any entity acting on behalf of the insurer, service company/TPA, shall bill on a Form DFS-F5-DWC-9 and enter his/her Florida Department of Health license number in Field 33b on the Form DFS-F5-DWC-9:
a. Any licensed physician; or
b. Any non-physician health care provider, including a physician assistant or an ARNP (not providing an anesthesia-related service); or
c. Any licensed non-physician health care provider who is seeking reimbursement under his or her license number issued by the Florida Department of Health.
4. For hospital billing, the following special requirements apply:
a. Inpatient billing – Hospitals shall, in addition to filing a Form DFS-F5-DWC-90:
I. Attach an itemized statement with charges based on the facility’s Charge Master; and
II. Submit all applicable documentation or certification required pursuant to Rule 69L-7.501, F.A.C.; and
III. Bill professional services provided by a physician, physician assistant, advanced registered nurse practitioner, or registered nurse first assistant on the Form DFS-F5-DWC-9, regardless of employment arrangement;
IV. When entering the CPT®, HCPCS or unique workers’ compensation codes in Form Locator 44 on the Form DFS-F5-DWC-90, the hospital shall utilize CPT®, HCPCS or unique workers’ compensation codes provided in the Florida Workers’ Compensation Health Care Provider Reimbursement Manual adopted in Rule 69L-7.501, F.A.C.
b. Outpatient billing – Hospitals shall in addition to filing a Form DFS-F5-DWC-90:
I. Enter the CPT®, HCPCS or unique workers’ compensation code (provided in the Florida Workers’ Compensation Health Care Provider Reimbursement Manual as incorporated for reference in Rule 69L-7.501, F.A.C.) in Form Locator 44 on the Form DFS-F5-DWC-90, to bill outpatient radiology, clinical laboratory and physical, occupational or speech therapy charges; and
II. Make written entry “scheduled” or “non-scheduled” in Form Locator 84 of Form revision 1992 and in Form Locator 80 of Form revision 2006 – ‘Remarks’ on the DFS-F5-DWC-90, when billing outpatient surgery or outpatient surgical services; and
III. Make written entry “implant(s)” followed by the reimbursement calculation made pursuant to Rule 69L-7.501, F.A.C., in Form Locator 84 of Form revision 1992 and in Form Locator 80 of Form revision 2006 – ‘Remarks’ on the DFS-F5-DWC-90, directly after entry of “scheduled” or “non-scheduled”, when present;
IV. Attach an itemized statement with charges based on the facility’s Charge Master if there is no line item detail shown on the Form DFS-F5-DWC-90; and
V. Submit all applicable documentation or certification required pursuant to Rule 69L-7.501, F.A.C.;
VI. Bill professional services provided by a physician, physician assistant, advanced registered nurse practitioner, or registered nurse first assistant on the Form DFS-F5-DWC-9, regardless of employment arrangement;
5. A certified, licensed physician assistant, anesthesia assistant and registered nurse first assistant who provides services as a surgical assistant, in lieu of a second physician, shall bill on a Form DFS-F5-DWC-9 entering the CPT® code(s) plus modifier(s), which represent the service(s) rendered, in Field 24D, and must enter his/her Florida Department of Health license number in Field 33b.
6. Ambulatory Surgical Centers (ASCs) shall bill on a Form DFS-F5-DWC-9 using the American Medical Association’s CPT® procedure codes, or using the unique workers’ compensation procedure code 99070 and billing charges based on the ASC’s Charge Master except when billing for procedure code 99070. ASC medical bills shall be accompanied by all applicable documentation required pursuant to Rule 69L-7.100, F.A.C.
7. Federal Facilities shall bill on their usual form.
8. Out-of-State health care providers shall bill on the applicable medical bill form pursuant to paragraph (4)(c) of this rule.
9. Dental Services.
a. Dentists shall bill for services on a Form DFS-F5-DWC-11.
b. Oral surgeons shall bill for oral and maxillofacial surgical services on a Form DFS-F5-DWC-9. Non-surgical dental services shall be billed on a Form DFS-F5-DWC-11.
10. Pharmaceutical(s), Durable Medical Equipment and Medical Supplies.
a. When dispensing commercially available medicinal drugs commonly known as legend or prescription drugs:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the NDC number, in the universal 5-4-2 format, in Field 9, with each segment separated by a dash (-).
II. Physicians, physician assistants or ARNPs shall bill on Form DFS-F5-DWC-9 and shall enter the NDC number, in the universal 5-4-2 format, in Field 24D, with each segment separated by a dash (-). Optionally, the unique workers’ compensation code 96370 may be entered in addition to the NDC number in Field 24D.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.
b. When dispensing medicinal drugs which are compounded and the prescribed formulation is not commercially available:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the unique workers’ compensation code 96371 in Field 9.
II. Physicians, physician assistants or ARNPs shall bill on Form DFS-F5-DWC-9 and shall enter the unique workers’ compensation code 96371 in form Field 24D.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.
c. When dispensing over-the-counter drug products:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the NDC number, in the universal 5-4-2 format in form Field 9, with each segment separated by a dash (-).
II. Physicians, physician assistants or ARNPs shall bill on Form DFS-F5-DWC-9, shall enter the NDC number in the universal 5-4-2 format, in Field 24D, with each segment separated by a dash (-). The requirement to enter the NDC number in Field 24D supersedes the instruction to enter 99070 in the Florida Workers’ Compensation Health Care Provider Reimbursement Manual.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.
d. When administering or dispensing injectable drugs:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the NDC number, in the universal 5-4-2 format, in form Field 9, with each segment separated by a dash (-).
II. Physicians, physician assistants or ARNPs shall bill on a Form DFS-F5-DWC-9 and enter the appropriate HCPCS “J” code in form Field 24D. When an appropriate HCPCS “J” code is not available for the injectable drug, enter the NDC number, in the universal 5-4-2 format in form Field 24D with each segment separated by a dash (-).
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.
e. When dispensing durable medical equipment (DME):
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in Field 21 on form revision 2/14/06 and in Field 21 on form revision 1/1/07.
II. Physicians, physician assistants or ARNPs shall bill on Form DFS-F5-DWC-9, shall enter the applicable HCPCS code in Field 24D and attach documentation indicating the actual cost of the supply, including applicable manufacturer’s shipping and handling.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the applicable revenue codes.
IV. Ambulatory Surgical Centers shall bill for these products on Form DFS-F5-DWC-9 using applicable HCPCS codes.
V. Medical Suppliers shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in form Field 21 on form revision 2/14/06 and in Field 21 on form revision 1/1/07. The requirement to enter the HCPCS code when billing for medical equipment or supplies supersedes the instruction that “the medical supplier is not required to submit codes” in the Florida Workers’ Compensation Health Care Provider Reimbursement Manual.
f. When dispensing medical supplies which are not incidental to a service or procedure:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in Field 16 on form revision 2/14/06 and in Field 21 on form revision 1/1/07.
II. Physicians, physician assistants or ARNPs shall bill on Form DFS-F5-DWC-9, shall enter the applicable HCPCS code in Field 24D and attach documentation indicating the actual cost of the supply, including applicable manufacturer’s shipping and handling. The requirement to enter the HCPCS code when billing for medical equipment or supplies supersedes the instruction “under the specific HCPCS code or 99070” in the Florida Workers’ Compensation Health Care Provider Reimbursement Manual.
III. Hospitals shall bill on Form DFS-F5-DWC-90 under the applicable revenue codes.
IV. Ambulatory Surgical Centers shall bill separately for these products on Form DFS-F5-DWC-9 and shall enter the applicable CPT® code or HCPCS in Field 24D.
V. Medical Suppliers shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in Field 16 on form revision 2/14/06 and in Field 19 on form revision 1/1/07. The requirement to enter the HCPCS code when billing for medical equipment or supplies supersedes the instruction that “the medical supplier is not required to submit codes” in the Florida Workers’ Compensation Health Care Provider Reimbursement Manual.
g. Pharmacists who provide Medication Therapy Management Services shall bill for these services on a Form DFS-F5-DWC-9 by entering the appropriate CPT® code(s) 0115T, 0116T or 0117T that represent the service(s) rendered in form Field 24D, shall enter their Florida Department of Health license number in Field 33b and shall submit a copy of the physician’s written prescription with the medical bill.
h. Pharmacists and medical suppliers may only bill on an alternate to Form DFS-F5-DWC-10 when an insurer has pre-approved use of the alternate form. Forms DFS-F5-DWC-9, DFS-F5-DWC-11 or DFS-F5-DWC-90 shall not be approved for use as the alternate form.
11. Physicians billing for a failed appointment for a scheduled independent medical examination (when the injured employee does not report to the physician office as scheduled) shall bill on their invoice or letterhead. The invoice shall not be a Form DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11, or DFS-F5-DWC-90.
12. Health care providers receiving reimbursement under any payment plan (pre-payment, prospective pay, capitation, etc.) must accurately complete the Form DFS-F5-DWC-9 and submit the form to the insurer.
13. Health care providers and other insurer-authorized providers rendering services reimbursable under workers’ compensation, whose billing requirements are not otherwise specified in this rule (e.g. home health agencies, independent, non-hospital based ambulance services, air- ambulance, emergency medical transportation, non-emergency transportation services, translation services, etc.) shall bill on their invoice or business letterhead. These providers shall not submit the Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11 or DFS-F5-DWC-90 as an invoice.
(c) Bill Completion.
1. Bills shall be legibly and accurately completed by all health care providers, regardless of location or reimbursement methodology, as set forth in this section and paragraph (4)(b) of this rule.
2. Billing elements required by the Division to be completed by a health care provider are identified in specific Form DFS-F5-DWC-9-A or Form DFS-F5-DWC-9-B (completion instructions), as appropriate for the date of the revised form, available at the following websites:
a. http://www.fldfs.com/wc/pdf/DWC-9instrHCP.pdf when submitted by Licensed Health Care Providers;
b. http://www.fldfs.com/wc/pdf/DWC-9instrASC.pdf when submitted by Ambulatory Surgical Centers;
c. http://www.fldfs.com/wc/pdf/DWC-9instrWHPM.pdf when submitted by Work Hardening and Pain Management Programs.
3. Billing elements required by the Division to be completed for Pharmaceutical or Medical Supplier Billing are identified in specific Form DFS-F5-DWC-10 (completion instructions), as appropriate for the date of the revised form, available at website: http://www.fldfs.com/WC/forms.html#7.
4. Billing elements required by the Division to be completed for Dental Billing are identified in specific Form DFS-F5-DWC-11-A or Form DFS-F5-DWC-9-B (completion instructions), as appropriate for the date of the revised form, available at website: http://www.fldfs.com/WC/forms.html#7.
5. Billing elements required by the Division to be completed for Hospital Billing are identified in the UB-92 Manual, the UB-04 Manual, Form DFS-F5-DWC-90-B (completion instructions) and subparagraph (4)(b)4. of this rule.
6. An insurer can require a health care provider to complete additional data elements that are not required by the Division on Form DFS-F5-DWC-9 or DFS-F5-DWC-11.
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