(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 a Certified Registered Nurse Anesthetist (CRNA) provides
anesthesia services, the CRNA 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. Recognized practitioners, except physician assistants, advanced
registered nurse practitioners, certified registered nurse anesthetists,
who are salaried employees of an authorized treating physician and, 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 report and bill for such services on
a Form DFS-F5-DWC-9 by entering the employing physician’s Florida
Department of Health license number in Field 33b on the Form
DFS-F5-DWC-9.
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 specifically requested and additional documentation
requested at the time of authorization; 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. Make written entry “implant(s)” followed by the reimbursement amount
calculated pursuant to Rule 69L-7.501, F.A.C., in Form Locator 80 of
Form revision 2006 – ‘Remarks’ on the DFS-F5-DWC-90, or certification
required pursuant to 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 workers’ compensation unique code and the
applicable CPT® or HCPCS modifier code in Form Locator 44 on the Form
DFS-F5-DWC-90, when required pursuant to the UB-04 Manual; and
II. Make written entry “scheduled” or “non-scheduled” 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. Attach an itemized statement with charges based on the facility’s
Charge Master; and
IV. Submit all applicable documentation required pursuant to Rule
69L-7.501, F.A.C.;
V. Bill professional services provided by a physician or recognized
practitioner on the Form DFS-F5-DWC-9, regardless of employment
arrangement;
5. A certified, licensed physician 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 as follows:
a. For dates of service up to and including 07/07/2010, ASCs shall bill
on Form DFS-F5-DWC-9 using the American Medical Association’s CPT®
procedure codes, or using the workers’ compensation unique procedure
code 99070 with required modifiers and shall bill charges based on the
ASC’s Charge Master except when billing for procedure code 99070.
b. For dates of service on or after 07/08/2010, Ambulatory Surgical
Centers shall bill on Form DFS-F5-DWC-90 and shall enter the CPT®, HCPCS
or workers’ compensation unique code and the applicable CPT® or HCPCS
modifer code in Form Locator 44 for each service rendered. ASCs shall
bill charges based on the ASC’s Charge Master except when billing for
surgical implants, associated disposable instrumentation and applicable
shipping and handling. ASCs shall use Revenue Center Code 0278 and
workers’ compensation unique code(s) with required modifier(s) pursuant
to Rule 69L-7.100, F.A.C., when billing for surgical implants,
associated disposable instrumentation, and applicable shipping and
handling pursuant to Rule 69L-7.100, F.A.C. ASC medical bills shall be
accompanied by all applicable documentation or certification required
pursuant to Rule 69L-7.100, F.A.C.
7. Home Health Agencies (HHAs) shall bill on Form DFS-F5-DWC-90.
a. For dates of service up to and including 07/07/2010, HHAs shall bill
on letterhead or invoice.
b. For dates of service on or after 07/08/2010, HHAs shall bill on Form
DFS-F5-DWC-90 and shall enter the CPT®, HCPCS or workers’ compensation
unique codes and the applicable CPT® or HCPCS modifer code in Form
Locator 44 for each service rendered.
8. Nursing Home Facilities shall bill on Form DFS-F5-DWC-90.
a. For dates of service up to and including 07/07/2010, Nursing Home
Facilities shall bill on letterhead or invoice.
b. For dates of service on or after 07/08/2010, Nursing Home Facilities
shall bill on Form DFS-F5-DWC-90 and shall enter the CPT®, HCPCS or
workers’ compensation unique code and the applicable CPT® or HCPCS
modifer code in Form Locator 44 for each service rendered.
9. Federal Facilities shall bill on their usual form.
10. Out-of-State health care providers shall bill on the applicable
medical bill form pursuant to paragraph (4)(c) of this rule.
11. Dental Services.
a. Dentists shall bill for services on 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
Form DFS-F5-DWC-11.
c. When dispensing medications, dentists and oral surgeons shall submit
charges on the forms specified in paragraphs 11.a. and 11.b. above.
12. Pharmaceutical(s), Durable Medical Equipment and Home Medical
Equipment or 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 (-). The
workers’ compensation unique code DSPNS must be entered in addition to
the NDC number in Field 24D. DME and medical supplies dispensed by a
physician or recognized practitioner during an office visit must be
billed on the DWC-9.
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
workers’ compensation unique code COMPD in Field 9.
II. Physicians, physician assistants or ARNPs shall bill on Form
DFS-F5-DWC-9 and shall enter the workers’ compensation unique code COMPD
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 (-).Medication
dispensed by a physician or recognized practitioner during an office
visit must be billed on the DWC-9.
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 3/1/2009.
II. Physicians and recognized practitioners 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.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the applicable
revenue codes.
IV. Home Medical Equipment Providers shall bill on Form DFS-F5-DWC-10
and shall enter the applicable HCPCS code in form Field 21 on form
revision 3/1/2009.
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 21 on form revision 3/1/2009.
II. Physicians and recognized practitioners 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.
III. Hospitals shall bill on Form DFS-F5-DWC-90 under the applicable
revenue codes.
IV. Home Medical Equipment Providers shall bill on Form DFS-F5-DWC-10
for DME supplies prescribed by a physician or recognized practitioner,
and shall enter the applicable HCPCS code in Field 21 on form revision
3/1/2009.
g. Pharmacists who provide Medication Therapy Management Services shall
bill for these services on Form DFS-F5-DWC-9 by entering the appropriate
CPT® code(s) 99605, 99606 or 99607 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.
13. 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 worker’s
compensation unique code 99456-CN on the DFS-F5-DWC-9.
14. 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.
15. Parties that are not physicians or recognized practitioners
authorized by an insurer to render services reimbursable under workers’
compensation shall bill on their invoice or letterhead. These parties
shall not bill using Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11 or
DFS-F5-DWC-90 as an invoice.
