19 Del. Admin. Code § 1341
1.3 Section 2322B(3),Chapter 23, Title 19, Delaware Code establishes the fee schedule framework for hospitals, ambulatory surgery centers, and professional servicesbased upon Resource Based Relative Value Scale (RBRVS), Medical Severity Diagnosis Related Group (MS-DRG), Ambulatory Payment Classification (APC) or other equivalent scale used by the Centers for Medicare and Medicaid Services, and Delaware geographic adjustments.
The following words and terms, when used in this regulation, have the following meaning:
“Certification” means the certification pursuant to19 Del.C. §2322D, required for a Health Care Provider to provide treatment to an employee, pursuant to Delaware’s Workers’ Compensation Statute.
“Certification of Health Care Providers in an Inpatient Hospital Setting." With regard to health care provider certification as required by 19 Del.C. §2322D, such certification applies to physicians, chiropractors, and physical therapists providing treatment to an injured worker during his or her period of inpatient hospitalization; all other personnel employed by a hospital providing treatment to an injured worker during his or her period of inpatient hospitalization are excluded from certification.
“ CPT ” means Current Procedural Terminology, copyright American Medical Association (AMA). CPT codes are also known as Healthcare Common Procedure Coding System (HCPCS) Level 1 and is the numeric medical coding system used in the HCPS for the professional services, as well as hospital outpatient, and ambulatory surgery centers fee schedules.
"Department" means the Department of Labor.
"Fee Schedule Amounts" mean the fees as set forth by the Health Care Payment System.
"Forms" means the standard health care provider and employer forms for the provision of health care services set forth in 19 Del.C. §2322E.
“ Geozip ” means the geographical area used to determine the “Delaware specific geographically adjusted factor” mandated in 19 Del.C. §2322B(a).
“ HCPCS ” means Healthcare Common Procedure Coding System. HCPCS level 1 consists of the American Medical Association’s Current Procedure Terminology (CPT. HCPCS level II codes are alphanumeric and primarily include non-physician services, items, and supplies not covered by the Level 1 (CPT) codes.
"Health Care Payment System" means the comprehensive fee schedule promulgated by the Workers’ Compensation Oversight Panel to establish medical payments for both professional and facility fees generated on workers' compensation claims.
“Health Care Provider Application for Certification” means the Department’s approved application form which Health Care Providers must submit to the Department so that pre-authorization of each health care procedure, office visit or health care service to be provided to the employee is not required.
“ MAR ” means maximum allowable reimbursement.
"Not Addressed" means when a code or service that is not present in the Delaware Fee Schedule. The code or service shall be reimbursed as a percent of charge per the applicable fee schedule.
"Not Covered" means that a fee is represented by $0.00 on the Delaware Fee Schedule. When a 0% is displayed in either the professional or technical component percentage of the professional fee schedule, the service is considered 100% of the other component. The component with the 0% is not reimbursed Percentage of Charge (POC).
“Utilization Review” means the utilization review program and associated procedures to guide utilization of health care treatments in workers’ compensation as set forth in Section 2322F(j), Chapter 23, Title 19,Delaware Code.
“ Workers’ Compensation Oversight Panel ” or “ Panel ” means the 24 members appointed or serving by virtue of position, pursuant to 19 Del.C. §2322A, to carry out the provisions of 19 Del.C. Ch. 23.
3.1 Section 2322D(a), Chapter 23, Title 19, Delaware Codeestablishes the minimum certification requirement to be certified as a Health Care Provider:
3.1.4 In accordance with the provisions of19 Del.C. §2322D, certification is required for a health care provider to provide treatment to a worker, pursuant to Delaware's Workers' Compensation Statute, without the requirement that the health care provider first pre-authorize each health care procedure, office visit or health care service to be provided to the employee with the employer if self-insured, or the employer's insurance carrier. Pursuant to 19 Del.C. §2322B and F, for purposes of the Certification requirements of §2322D, "health care provider in an inpatient hospital setting” specifically includes physicians, chiropractors and physical therapists providing treatment to an injured worker during the worker's period of inpatient hospitalization; all other personnel employed by a hospital providing treatment to an injured worker during the worker's period of inpatient hospitalization are excluded from the Certification requirements of subsection 3.1.4 of this regulation. With regard to any hospital facility providing inpatient and/or outpatient services, to be Certified in accordance with the provisions of §2322D so that pre-authorization from the employer or insurance carrier for the employer is not required for each health care procedure, office visit or health care service provided to an injured worker, the person completing and signing the Health Care Provider Application for Certification on behalf of the hospital shall have the authority to do so and must attest to and be responsible for the completion of all of the requirements set forth on such Application. Services provided by an emergency department of a hospital shall not be subject to the requirement of Certification. The provisions of §2322D shall apply to all treatments to workers provided after the effective date of the rule/regulation provided by subsection 3.1.4 of this regulation and regardless of the date of injury. A health care provider shall be certified only upon meeting the following minimum certification requirements:
3.1.5 In addition to the above, the health care provider to be certified must agree to the terms and conditions set forth on the Health Care Provider Application for Certification, as follows:
3.2 Completed Certification should be mailed to:
State of Delaware Department of Labor
Office of Workers’ Compensation
4425 N. Market Street
Wilmington, DE 19802
4.1 Introduction and Purpose
4.1.4 The physician, as well as hospital outpatient and ambulatory surgery centerfee schedules include fee amounts for specific medical services and procedures as identified using the following:
4.2 Format of the Fee Schedule.This fee schedule represents the maximum amount of reimbursement providers may receive for medical or surgical services for the treatment of work-related injuries and illnesses covered under the workers' compensation laws of the State of Delaware.
4.2.1 The maximum allowable reimbursement for individual reimbursement codes is generally separable into 11 distinct sections – Evaluation and Management (E&M); Anesthesia; Surgery; Radiology; Pathology and Laboratory; General Medicine; Physical Therapy; Hospital Outpatient; Ambulatory Surgery Center; Inpatient Hospital; and HCPCS – based on the category or type of service rendered. Each category of service has separate instructions for the application of ground rules and modifier adjustments. For each procedure, the fee schedule table includes the following details (if applicable):
4.2.4 General Medical Services Categories CPT Codes
| Evaluation & Management | 99091, 99202–99499 |
| Anesthesia | 00100–01999, 99100–99140 |
| Surgery | 10004–69990 |
| Radiology | 70010–79999 |
| Pathology & Laboratory | 80047-89398 |
| General Medicine | 90281–96999, 97802–97804, 98960–99082, 99151-99199, 99500-99607 |
| Physical Medicine | 97010–97799, 97810–98943 |
| HCPCS | A0021-V5364 |
4.2.5 Reference Materials. The health care payment system and fee schedule is in accordance with the following documents, including codes, guidelines and modifiers:
4.4 Professional Services/CPT Code Set
4.5 Physician/Health Care Provider Services
4.6 Modifiers. Modifiers augment CPT codes to more accurately describe the circumstances of services provided. When applicable, the circumstances should be identified by a modifier code: a 2-digit number placed after the usual procedure code. If more than 1 modifier is needed, place modifier 99 after the procedure code to indicate that 2 or more modifiers will follow.
4.6.1 No reductions in payment will be made when the modifiers below are billed, unless otherwise specified in the regulations.
22 Increased Procedural Services:When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, and physical and mental effort required). Note:This modifier should not be appended to an E/M service.
23 Unusual Anesthesia:Occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding modifier 23 to the procedure code of the basic service.
24 Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period:The physician or other qualified health care professional may need to indicate that an E/M service was performed during a postoperative period for a reason unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.
25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or other qualified Health Care Professional on the Same Day of the Procedure or Other Service:It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.
26 Professional Component: Certain procedures are a combination of a physician or other qualified health care professional component and a technical component. When the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
27 Multiple Outpatient Hospital E/M Encounters on the Same Date: For hospital outpatient reporting purposes, utilization of hospital resources related to separate and distinct E/M encounters performed in multiple outpatient hospital settings on the same date may be reported by adding modifier 27 to each appropriate level outpatient and/or emergency department E/M code(s). This modifier provides a means of reporting circumstances involving evaluation and management services provided by physician(s) in more than 1 (multiple) outpatient hospital setting(s) (e.g., hospital emergency department, clinic). Note: This modifier is not to be used for physician reporting of multiple E/M services performed by the same physician on the same date. For physician reporting of all outpatient evaluation and management services provided by the same physician on the same date and performed in multiple outpatient setting(s) (e.g., hospital emergency department, clinic), see Evaluation and Management, Emergency Department, or Preventive Medicine Services codes.
32 Mandated Services:Services related to mandated consultation and/or related services (e.g., third party payer, governmental, legislative or regulatory requirement) may be identified by adding modifier 32 to the basic procedure.
47 Anesthesia by Surgeon:Regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (This does not include local anesthesia.) Note: Modifier 47 would not be used as a modifier for the anesthesia procedures.
50 Bilateral Procedure:Unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code.
Note: This modifier should not be appended to designated "add-on" codes (see Appendix D of CPT).
State Note: There will be no reductions to the procedures billed with the modifier 50.
State Note: Procedure performed bilaterally are reported as 2-line items and modifier 50 is not appended. These codes are identified with CPT specific language at the code or subsection level. Modifiers RT and LT may be appended as appropriate.
51 Multiple Procedures: When multiple procedures, other than E/M services, Physical Medicine and Rehabilitation services or provision of supplies (e.g., vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). Note: This modifier should not be appended to designated “add-on” codes (see Appendix D of CPT).
State Note: There will be no reductions to the procedures billed with the modifier 51.
52 Reduced Services:Under certain circumstances, a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of modifier 52 signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note:For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use of CPT).
53 Discontinued Procedure:Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. Note:This modifier is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use of CPT).
54 Surgical Care Only:When 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.
55 Postoperative Management Only:When 1 physician or other qualified health care professional performed the postoperative management and another physician performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number.
56 Preoperative Management Only:When 1 physician or other qualified health care professional performed the preoperative care and evaluation and another physician performed the surgical procedure, the preoperative component may be identified by adding modifier 56 to the usual procedure number.
57 Decision for Surgery:An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service.
58 Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period:It may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance maybe reported by adding modifier 58 to the staged or related procedure. Note:For treatment of a problem that requires a return to the operating or procedure room (e.g., unanticipated clinical condition), see modifier 78.
59 Distinct Procedural Service:Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note:Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.
State Note: There will be no reductions to procedures billed with modifier 59.
62 Two Surgeons:When 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. Note:If a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
66 Surgical Team:Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians or other qualified health care professionals, often of different specialties, plus other highly skilled, specialty trained personnel, various types of complex equipment) are carried out under the “surgical team” concept. Such circumstances may be identified by each participating individual with the addition of modifier 66 to the basic procedure number used for reporting services.
73 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient's surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general). Under these circumstances, the intended service that is prepared for but canceled can be reported by its usual procedure number and the addition of modifier 73.Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.
74 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc.). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. Note:The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.
76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional:It may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service. Note:This modifier should not be appended to an E/M service.
77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional:It may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 77 to the repeated procedure or service. Note:This modifier should not be appended to an E/M service.
78 Unplanned Return to the Operating Room/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period:It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of the operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedures, see modifier 76.)
79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period:The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79. (For repeat procedures on the same day, see modifier 76.)
80 Assistant Surgeon:Surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
81 Minimum Assistant Surgeon:Minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number.
82 Assistant Surgeon (when qualified resident surgeon not available):The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
90 Reference (Outside) Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician or other qualified health care professional, the procedure may be identified by adding modifier 90 to the usual procedure number.
91 Repeat Clinical Diagnostic Laboratory Test: In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91. Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.
92 Alternative Laboratory Platform Testing: When laboratory testing is being performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable analytical chamber, the service may be identified by adding modifier 92 to the usual laboratory procedure code (HIV testing 86701–86703 and 87389). The test does not require permanent dedicated space; hence by its design it may be hand carried or transported to the vicinity of the patient for immediate testing at that site, although location of the testing is not in itself determinative of the use of this modifier.
93 Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System: Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located away at a distant site from the physician or other qualified health care professional. The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that is sufficient to meet the key components or requirements of the same service when rendered via a face-to-face interaction.
95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System: Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. The totality of the communication of information exchanged between the physician or other qualified health care professional and patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components or requirements of the same service when rendered via a face-to-face interaction. Modifier 95 may only be appended to the services listed in Appendix P (of CPT). Appendix P is the list of CPT codes for services that are typically performed face-to-face, but may be rendered via real-time (synchronous) interactive audio and video telecommunications system.
96 Habilitative Services: When a service or procedure that may be either habilitative or rehabilitative in nature is provided for habilitative purposes, the physician or other qualified health care professional may add modifier 96 to the service or procedure code to indicate that the service or procedure provided was a habilitative service. Habilitative services help an individual learn skills and functioning for daily living that the individual has not yet developed, and then keep or improve those learned skills. Habilitative services also help an individual keep, learn, or improve skills and functioning for daily living.
97 Rehabilitative Services: When a service or procedure that may be either habilitative or rehabilitative in nature is provided for rehabilitative purposes, the physician or other qualified health care professional may add modifier 97 to the service or procedure code to indicate that the service or procedure provided was a rehabilitative service. Rehabilitative services help an individual keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the individual was sick, hurt, or disabled.
99 Multiple Modifiers:Under certain circumstances, 2 or more modifiers may be necessary to completely delineate a service. In such situations, modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service.
TC Technical Component Only:Certain procedures are a combination of a physician component and a technical component. When the technical component is reported separately by a physician or clinic, the service may be identified by adding modifier TC to the usual procedure number.
PA Services Performed by a Physician Assistant: When services of a physician assistant are performed, identify the services by adding modifier PA to the usual procedure code.
NP Services Performed by a Nurse Practitioner: When services of a nurse practitioner are performed, identify the services by adding modifier NP to the usual procedure code.
AA Anesthesia Services Performed Personally by Anesthesiologist:Report modifier AA when the anesthesia services are personally performed by an anesthesiologist.
AD Medical Supervision by a Physician: More Than 4 Concurrent Anesthesia Procedures:Report modifier AD when the anesthesiologist supervises more than 4 concurrent anesthesia procedures.
G8 Monitored Anesthesia Care (MAC) for Deep, Complex, Complicated or Markedly Invasive Surgical Procedures:Report modifier G8 when monitored anesthesia care is required for deep, complex, complicated, or markedly invasive surgical procedures.
G9 Monitored Anesthesia Care for Patient Who Has a History of Severe Cardiopulmonary Condition:Report modifier G9 when monitored anesthesia care is required for a patient who has a history of severe cardiopulmonary condition.
QK Medical Direction of 2, 3, or 4 Concurrent Anesthesia Procedures Involving Qualified Individuals:Report modifier QK when the anesthesiologist supervises 2, 3, or 4 concurrent anesthesia procedures.
QS Monitored Anesthesia Care Service:The QS modifier is for informational purposes.
QX CRNA Service with Medical Direction by a Physician:Regional or general anesthesia provided by the CRNA with medical direction by a physician may be reported by adding modifier QX.
QY Medical Supervision of 1 CRNA by an Anesthesiologist:Report modifier QY when the anesthesiologist supervises 1 CRNA.
QZ CRNA Service without Medical Direction by a Physician:Regional or general anesthesia provided by the CRNA without medical direction by a physician may be reported by adding modifier QZ.
4.7 Hospital Outpatient and Ambulatory Surgical Treatment Methodology
4.7.7 Hospital Outpatient and Ambulatory Surgery Center (ASC) Fee Schedule Methodology:
4.8 Dental Services
4.10 Inpatient Hospital
4.10.2 Definition.A hospital (other than psychiatric) means an institution which is primarily engaged in providing, by or under the supervision of physicians, to inpatients, diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons; or rehabilitation services for the rehabilitation of injured, disabled, or sick persons. To be eligible to participate in Medicare, a hospital must also be an institution which:
4.10.4 The hospital fee schedule methodology is as follows:
4.10.5 Other Inpatient Facility Fees
4.10.6 Inpatient Care
4.10.6.2 Billing and Reimbursement Rules for Inpatient Care
4.10.6.2.3 Non-covered charges include but are not necessarily limited to:
4.10.6.2.4 When reviewing surgical claims the following apply:
4.10.6.2.4.1 Most of the following operative procedures require cardiopulmonary monitoring either by the physician performing the procedure or an anesthesiologist/anesthetist. Because these services are integral to the operating room environment, these are considered as part of the OR fee and are not separately reimbursed:
4.10.7 Observation Services
4.10.7.2 General Guidelines
4.10.7.2.3 Services which are NOT considered necessary for observation are as follows:
4.11 Other Qualified Health Care Professional
4.12 Independently Operated Diagnostic Testing Facility
4.13 Pathology
4.14 Pharmacy
4.14.2 Definitions:
The following words and terms, when used in this regulation, have the following meaning:
"Average Wholesale Price" or "AWP" means the average wholesale price of a prescription drug as provided in the most current release of the Medi-Span Master Drug Database by Wolters Kluwar Health on the day a prescription drug is dispensed or other nationally recognized drug pricing index adopted by the Workers’ Compensation Oversight Panel.
"Brand name drug" means a drug for which an application is approved under the Federal Food, Drug, and Cosmetic Act Section 505(c).
"Generic drug" means a drug for which an application is approved under the Federal Food, Drug, and Cosmetic Act Section 505(j).
4.15 Total Component/Professional Component, Technical Component
4.16 Billing and Payment for Health Care Services
4.17 Fees for Non-Clinical Services
4.17.1 Pursuant to19 Del.C. §2322B(13), fees for certain non-clinical services are set as follows, and will be periodically revised upon recommendation of the Workers’ Compensation Oversight Panel to reflect changes in the cost of providing such services:
4.17.1.1 Retrieving, copying and transmitting existing medical reports and records, to include copying of medical notes and/or records supporting a bill or invoice for charges for treatment or services:
4.18 Effective Date
4.19 General Rules
4.19.1 Definitions
The following words and terms, when used in this regulation, have the following meaning:
“Adjust” means that a payer or a payer's agent reduces or otherwise alters a health care provider's request for payment.
“Appropriate care” means health care that is suitable for a particular patient, condition, occasion, or place.
“Bill” means a claim submitted by a provider to a payer for payment of health care services provided in connection with a covered injury or illness.
“Bill adjustment” means a reduction of a fee on a provider's bill, or other alteration of a provider's bill.
“Carrier” means any stock company, mutual company, or reciprocal or inter-insurance exchange authorized to write or carry on the business of Workers' Compensation Insurance in this State, or self-insured group, or third-party payer, or self-insured employer, or uninsured employer.
“CMS-1500” means the CMS-1500 form and instructions that are used by non institutional providers and suppliers to bill for outpatient services. Use of the most current CMS-1500 form is required.
“Case” means a covered injury or illness occurring on a specific date and identified by the worker's name and date of injury or illness.
“Consultation” means a service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. If a consultant, subsequent to the first encounter, assumes responsibility for management of the patient's condition, that physician becomes a treating physician. The first encounter is a consultation and shall be billed and reimbursed as such. A consultant shall provide a written report of his/her findings. A second opinion is considered a consultation.
“Critical care” means care rendered in a variety of medical emergencies that requires the constant attention of the practitioner, such as cardiac arrest, shock, bleeding, respiratory failure, postoperative complications, and is usually provided in a critical care unit or an emergency department.
“Day” means a continuous 24-hour period.
“Diagnostic procedure” means a service that helps determine the nature and causes of a disease or injury.
“Durable medical equipment (DME)” means specialized equipment designed to stand repeated use, appropriate for home use, and used solely for medical purposes.
“Expendable medical supply” means a disposable article that is needed in quantity on a daily or monthly basis.
“Follow-up care” means the care which is related to the recovery from a specific procedure and which is considered part of the procedure's maximum reimbursement allowance, but does not include complications.
“Follow-up days” are the days of care following a surgical procedure which are included in the procedure's maximum reimbursement allowance amount, but which do not include complications. The follow-up day period begins on the day of the surgical procedure(s).
“Independent procedure” means a procedure that may be carried out by itself, completely separate and apart from the total service that usually accompanies it.
“Inpatient services” means services rendered to a person who is admitted as an inpatient to a hospital.
“Medical record” means a record in which the medical service provider records the subjective findings, objective findings, diagnosis, treatment rendered, treatment plan, and return to work status and/or goals and impairment rating as applicable.
“Medical supply” means either a piece of durable medical equipment or an expendable medical supply.
“Observation services” means services rendered to a person who is designated or admitted as observation status.
“Operative report” means the practitioner's written description of the surgery and includes all of the following:
| • | A preoperative diagnosis; |
| • | A postoperative diagnosis; |
| • | A step-by-step description of the surgery; |
| • | A description of any problems that occurred in surgery; and |
| • | The condition of the patient upon leaving the operating room. |
“Optometrist” means an individual licensed to practice optometry.
“Orthotic equipment” means an orthopedic apparatus designed to support, align, prevent, or correct deformities, or improve the function of a movable body part.
“Orthotist” means a person skilled in the construction and application of orthotic equipment.
“ Other Qualified Health Care Professional ” (OQHP) means the following professionals (please note this list is not all inclusive): nurse practitioner (NP), certified registered nurse anesthetist (CRNA), certified registered nurse (CRN), clinical nurse specialist (CNS), and physician assistant (PA).
“Outpatient service” means services provided to patients at a time when they are not hospitalized as inpatients.
“Payer” means the employer or self-insured employer group, carrier, or third-party administrator (TPA) who pays the provider billings.
“Pharmacy” means the place where the science, art, and practice of preparing, preserving, compounding, dispensing, and giving appropriate instruction in the use of drugs is practiced.
“Physician Specialty”. The rules and reimbursement allowances in the Delaware Workers' Compensation Health Care Payment System do not address physician specialization within a specialty. Payment is not based on the fact that a physician has elected to treat patients with a particular/specific problem. Reimbursement to qualified physicians is the same amount regardless of specialty.
“Procedure code” means a five-digit numerical sequence or a sequence containing an alpha character and preceded or followed by four digits, which identifies the service performed and billed.
“Prosthesis” means an artificial substitute for a missing body part.
“Prosthetist” means a person skilled in the construction and application of prostheses.
“Provider” means a facility, health care organization, or a practitioner who provides medical care or services.
“Secondary procedure” means a surgical procedure performed during the same operative session as the primary surgery but considered an independent procedure that may not be performed as part of the primary surgery.
4.19.2 Injections
4.19.3 General Ground Rules
4.19.3.3 Separate Procedures
4.19.3.6 Ground Rules for Physician Assistants (PA) and Nurse Practitioners (NP)
4.19.3.6.1 Physician Supervision. The term "supervise," for billing purposes, encompasses the following supervision requirement:
4.19.3.6.1.2 However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the PA or NP is performing the services.
4.19.3.6.3 Management of a New or Established Patient with a New Workers' Compensation Problem
4.20 Evaluation and Management
4.20.1 Payment Ground Rules for E/M Category
4.20.1.1 General Guidelines
4.20.1.2 Definitions. Certain key words and phrases are used throughout the E/M section. The following definitions are intended to reduce the potential for differing interpretations and to increase the consistency of reporting by physicians in differing specialties.
4.20.1.2.1 New and Established Patient
4.20.1.2.5 Counseling. Counseling is a discussion with an injured employee and/or family concerning 1 or more of the following areas:
4.20.2 Payment Modifiers for E/M Category
4.20.2.2 The modifiers listed in subsection 4.20.2.2 of this regulation may differ from those published by the American Medical Association. Medical providers submitting workers' compensation billing shall use only the modifiers set out in the fee schedule. The following modifiers will be recognized for reimbursement by the fee schedule for Evaluation and Management (E/M) codes:
24 Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional during a Postoperative Period: The physician or other qualified health care professional may need to indicate that an E/M service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.
25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or other qualified Health Care Professional on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report and E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.
32 Mandated Services:Services related to mandated consultation and/or related services (e.g., third party payer, governmental, legislative or regulatory requirement) may be identified by adding modifier 32 to the basic procedure.
52 Reduced Services: Under certain circumstances, a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use).
53 Discontinued Procedure: Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use).
57 Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service.
93 Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System: Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located away at a distant site from the physician or other qualified health care professional. The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that is sufficient to meet the key components or requirements of the same service when rendered via a face-to-face interaction.
95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System: Synchronous telemedicine services is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. Modifier 95 may only be appended to the services listed in Appendix P (of CPT). Appendix P is the list of CPT codes for services that are typically performed face-to-face, but may be rendered via real-time (synchronous) interactive audio and video telecommunications system.
99 Multiple Modifiers:Under certain circumstances, 2 or more modifiers may be necessary to completely delineate a service. In such situations, modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service.
4.21 Anesthesia
4.21.1 Introduction
4.21.2 Special Circumstances
4.21.2.1 Physical Status Modifiers
4.21.2.1.1 Physical status modifiers are represented by the initial letter P followed by a single digit from 1 to 6 representing these Status Description Units:
4.21.2.2 Qualifying Circumstances
4.21.2.2.1 Many anesthesia services are provided under particularly difficult circumstances, depending on factors such as extraordinary condition of patient, notable operative conditions, and/or unusual risk factors. This section includes a list of important qualifying circumstances that significantly affect the character of the anesthesia service provided. These procedures would not be reported alone but would be reported as additional procedure numbers qualifying an anesthesia procedure or service.
4.21.2.2.1.1 More than 1 qualifying circumstance may be selected.
99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) 1.
99116 Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure) 5.
99135 Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure) 5.
99140 Anesthesia complicated by emergency conditions (specify conditions) (List separately in addition to code for primary anesthesia procedure) (An emergency is defined as existing when delay in treatment of a patient would lead to a significant increase in the threat to life or body part.) 2.
4.21.4 Reimbursement for Anesthesia Services
4.21.4.1 Criteria for Reimbursement. Anesthesia services may be billed for any 1 of the 3 following circumstances:
4.21.4.1.3 Anesthesia provided by a CRNA working independent of an anesthesiologist's supervision is covered under the following conditions:
4.21.4.2 Reimbursement
4.21.4.2.4 Payment for covered anesthesia services is as follows:
4.21.4.2.5 Anesthesiologists, CRNAs must bill their services with the appropriate modifiers to indicate which one provided the service. Bills NOT properly coded may cause a delay or error in reimbursement by the payer. Application of the appropriate modifier to the bill for service is the responsibility of the provider, regardless of the place of service. Modifiers are as follows:
AA Anesthesiologist services performed personally by an anesthesiologist.
AD Medical supervision by a physician: more than 4 concurrent anesthesia procedures.
QK Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals (CRNA) by an anesthesiologist.
QX CRNA service: with medical direction by a physician.
QY Medical direction of 1 certified registered nurse anesthetist (CRNA) by an anesthesiologist.
QZ CRNA service: without medical direction by an anesthesiologist.
4.21.5 Anesthesia Modifiers. All anesthesia services are reported by using the anesthesia five-digit procedure codes. The fee for most procedures may be modified under certain circumstances as listed below. When applicable, the modifying circumstances should be identified by the addition of the appropriate modifier (including the hyphen) after the usual anesthesia code. Certain modifiers require a special report for clarification of services provided.
4.21.5.1 Modifiers commonly used in anesthesia are as follows:
22 Increased Procedural Services:When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, and physical and mental effort required). Note: This modifier should not be appended to an E/M service.
23 Unusual Anesthesia: Occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding modifier 23 to the procedure code of the basic service.
32 Mandated Services: Services related to mandated consultation and/or related services (e.g., third-party payer, governmental, legislative, or regulatory requirement) may be identified by adding modifier 32 to the basic procedure.
47 Anesthesia by Surgeon:Regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (This does not include local anesthesia.) Note: Modifier 47 would not be used as a modifier for the anesthesia procedures.
53 Discontinued Procedure: Under certain circumstances the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use).
59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier available, and use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.
AA Anesthesia Services Performed Personally by Anesthesiologist: Report modifier AA when the anesthesia services are personally performed by an anesthesiologist.
AD Medical Supervision by a Physician: More Than 4 Concurrent Anesthesia Procedures: Report modifier AD when the anesthesiologist supervises more than 4 concurrent anesthesia procedures.
G8 Monitored Anesthesia Care (MAC) for Deep, Complex, Complicated or Markedly Invasive Surgical Procedures:Report modifier G8 when monitored anesthesia care is required for deep, complex, complicated, or markedly invasive surgical procedures.
G9 Monitored Anesthesia Care for Patient Who Has a History of Severe Cardiopulmonary Condition:Report modifier G9 when monitored anesthesia care is required for a patient who has a history of severe cardiopulmonary condition.
QK Medical Direction of 2, 3, or 4 Concurrent Anesthesia Procedures Involving Qualified Individuals: Report modifier QK when the anesthesiologist supervises 2, 3, or 4 concurrent anesthesia procedures.
QS Monitored Anesthesia Care Service:The QS modifier is for informational purposes.
QX CRNA Service with Medical Direction by a Physician (Modified by State): Regional or general anesthesia provided by the CRNA with medical direction by a physician may be reported by adding modifier QX.
QY Medical Supervision of 1 CRNA by an Anesthesiologist (Modified by State): Report modifier QY when the anesthesiologist supervises 1 CRNA.
QZ CRNA Service without Medical Direction by a Physician (Modified by State): Regional or general anesthesia provided by the CRNA without medical direction by a physician may be reported by adding modifier QZ.
4.21.6 Moderate (Conscious) Sedation
4.21.6.3 When providing moderate sedation, the following services are included and NOT reported separately:
4.22 Surgery
4.22.1 General Guidelines
4.22.1.1 Global Reimbursement. The reimbursement allowances for surgical procedures are based on a global reimbursement concept that covers performing the basic service and the normal range of care required after surgery. Global reimbursement includes:
4.22.1.11 Surgical Assistant
4.22.1.11.2 Registered Nurse Surgical Assistant or Physician Assistant
4.22.1.19 Modifiers for Surgery
22 Increased Procedural Services:When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, and physical and mental effort required). Note:This modifier should not be appended to an E/M service.
25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or other qualified Health Care Professional on the Same Day of the Procedure or Other Service:It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.
26 Professional Component:Certain procedures are a combination of a physician or other qualified health care professional component and a technical component. When the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
47 Anesthesia by Surgeon:Regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (This does not include local anesthesia.) Note: Modifier 47 would not be used as a modifier for the anesthesia procedures.
50 Bilateral Procedure:Unless otherwise identified in the listings, bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate five-digit code. Note: This modifier should not be appended to designated "add-on" codes (see Appendix D of CPT).
State Note: There will be no reductions to the procedures billed with the modifier 50.
State Note:Procedures performed bilaterally are reported as 2 line items and modifier 50 is not appended. These codes are identified with CPT specific language at the code or subsection level. Modifiers RT and LT may be appended as appropriate.
51 Multiple Procedures:When multiple procedures, other than E/M services, physical medicine and rehabilitation services, or provision of supplies (e.g., vaccines) are performed at the same session by the same individual, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). Note:This modifier should not be appended to designated “add-on” codes (see Appendix D of CPT).
State Note: There will be no reductions to the procedures billed with the modifier 51.
52 Reduced Services:Under certain circumstances, a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of modifier 52 signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note:For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use (of CPT)).
53 Discontinued Procedure:Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. Note:This modifier is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use (of CPT)).
54 Surgical Care Only:When 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.
55 Postoperative Management Only:When 1 physician or other qualified health care professional performed the postoperative management and another physician performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number.
56 Preoperative Management Only:When 1 physician or other qualified health care professional performed the preoperative care and evaluation and another physician performed the surgical procedure, the preoperative component may be identified by adding modifier 56 to the usual procedure number.
57 Decision for Surgery:An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service.
58 Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period:It may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance maybe reported by adding modifier 58 to the staged or related procedure. Note:For treatment of a problem that requires a return to the operating or procedure room (e.g., unanticipated clinical condition), see modifier 78.
59 Distinct Procedural Service:Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note:Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.
State Note: There will be no reductions to the procedures billed with the modifier 59.
62 Two Surgeons:When 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. Note:If a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
66 Surgical Team:Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians or other qualified health care professionals, often of different specialties, plus other highly skilled, specialty trained personnel, various types of complex equipment) are carried out under the “surgical team” concept. Such circumstances may be identified by each participating individual with the addition of modifier 66 to the basic procedure number used for reporting services.
76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional:It may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service. Note:This modifier should not be appended to an E/M service.
77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional:It may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 77 to the repeated procedure or service. Note:This modifier should not be appended to an E/M service.
78 Unplanned Return to the Operating Room/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period:It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of the operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedures, see modifier 76.)
79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period:The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79. (For repeat procedures on the same day, see modifier 76.)
80 Assistant Surgeon:Surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
81 Minimum Assistant Surgeon:Minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number.
82 Assistant Surgeon (when qualified resident surgeon not available): The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
99 Multiple Modifiers:Under certain circumstances, 2 or more modifiers may be necessary to completely delineate a service. In such situations, modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service.
TC Technical Component Only:Certain procedures are a combination of a physician component and a technical component. When the technical component is reported separately, the service may be identified by adding modifier TC to the usual procedure number.
4.23 Hospital Outpatient and Ambulatory Surgery Centers
4.23.1 Definitions
4.23.2 Coding and Billing Rules
4.23.2.3 The payment rate for an ASC surgical procedure includes all facility services directly related to the procedure performed on the day of surgery. Facility services include:
4.23.2.5 Separate payment is not made for the following services that are directly related to the surgery:
4.23.5 Status Indicators (SI)
4.23.5.2 The following is a list of the accepted status indicators (SI) for use with hospital OPPS:
| Indicators | Item/Code/Service | OPPS Payment Status |
| A | Services furnished to a hospital outpatient that are paid under a fee schedule or payment system other than OPPS, for example: • Ambulance Services • Separately Payable Clinical Diagnostic Laboratory Services • Non-Implantable Prosthetic and Orthotic Devices • EPO for ESRD Patients • Physical, Occupational, and Speech Therapy • Diagnostic Mammography •Screening Mammography | Not paid under OPPS. Paid by fiscal intermediaries/MACs under a fee schedule or payment system other than OPPS. Services are subject to deductible or coinsurance unless indicated otherwise. Not subject to deductible or coinsurance. Not subject to deductible or coinsurance. State Note: Fee schedule currently incorporates the professional fee schedule amount or POC if not in professional schedule. |
| B | Codes that are not recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x). | Not paid under OPPS. • May be paid by fiscal intermediaries/MACs when submitted on a different bill type, for example, 75x (CORF), but not paid under OPPS. •An alternate code that is recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x) may be available. State Note: Fee schedule currently incorporates the professional fee schedule amount or POC if not in professional schedule. |
| C | Inpatient Procedures | Not paid under OPPS. Admit patient. Bill as inpatient. State Note: Reimburse as POC. |
| D | Discontinued Codes | Not paid under OPPS or any other Medicare payment system. |
| E | Items, Codes, and Services: • That are not covered by any Medicare outpatient benefit based on statutory exclusion. • That are not covered by any Medicare outpatient benefit for reasons other than statutory exclusion • That are not recognized by Medicare for outpatient claims but for which an alternate code for the same item or service may be available. •For which separate payment is not provided on outpatient claims | Not paid by Medicare when submitted on outpatient claims (any outpatient bill type). State Note: Fee schedule currently incorporates the professional fee schedule amount or POC if not in professional schedule. |
| F | Corneal Tissue Acquisition; Certain CRNA Services and Hepatitis B Vaccines | Not paid under OPPS. Paid at reasonable cost. State Note: Fee schedule currently incorporates the professional fee schedule amount or POC if not in professional schedule. |
| G | Pass-Through Drugs and Biologicals | Paid under OPPS; separate APC payment. State Note: Fee schedule currently incorporates the professional fee schedule amount or POC if not in professional schedule. |
| H | Pass-Through Device Categories | Separate cost-based pass-through payment; not subject to copayment. State Note: Fee schedule currently incorporates the professional fee schedule amount or POC if not in professional schedule. |
| K | Non Pass-Through Drugs and Non implantable Biologicals, Including Therapeutic Radiopharmaceuticals | Paid under OPPS; separate APC payment. State Note: Fee schedule currently incorporates the professional fee schedule amount or POC if not in professional schedule. |
| L | Influenza Vaccine; Pneumococcal Pneumonia Vaccine | Not paid under OPPS. Paid at reasonable cost; not subject to deductible or coinsurance. State Note: Fee schedule currently incorporates the professional fee schedule amount or POC if not in professional schedule. |
| M | Items and Services Not Billable to the Fiscal Intermediary/MAC | Not paid under OPPS. State Note: Fee schedule currently incorporates the professional fee schedule amount or POC if not in professional schedule. |
| N | Items and Services Packaged into APC Rates | Paid under OPPS; payment is packaged into payment for other services. Therefore, there is no separate APC payment. State Note: No payment unless otherwise specified/identified as POC on the hospital outpatient or ASC fee schedule. |
| P | Partial Hospitalization | Paid under OPPS; per diem APC payment. State Note: Reimburse as POC. |
| Q1 | STV-Packaged Codes | Paid under OPPS; Addendum B displays APC assignments when services are separately payable. (1) Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator “S,” “T,” “V,” or “X.” (2) In other circumstances, payment is made through a separate APC payment. State Note: Values are displayed in fee schedule per APC values. But payment may be packaged or adjusted per rules. |
| Q2 | T-Packaged Codes | Paid under OPPS; Addendum B displays APC assignments when services are separately payable. (1) Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator T. (2) In other circumstances, payment is made through a separate APC payment. State Note: Values are displayed in fee schedule per APC values. But payment must be packaged or adjusted per rules. |
| Q3 | Codes That May Be Paid Through a Composite APC | Paid under OPPS; Addendum B displays APC assignments when services are separately payable. Addendum M displays composite APC assignments when codes are paid through a composite APC. (1) Composite APC payment based on OPPS composite-specific payment criteria. Payment is packaged into a single payment for specific combinations of services. (2) In other circumstances, payment is made through a separate APC payment or packaged into payment for other services. State Note: Values are displayed in fee schedule per APC values. But payment may be packaged or adjusted per rules. |
| R | Blood and Blood Products | Paid under OPPS; separate APC payment. State Note: Values are displayed in fee schedule per APC values. |
| S | Procedure or Service, Not Discounted When Multiple | Paid under OPPS; separate APC payment. State Note: Values are displayed in fee schedule per APC values. |
| T | Procedure or Service | Paid under OPPS; separate APC payment. State Note: Values are displayed in fee schedule per APC values. Multiple procedure reductions do not apply. |
| U | Brachytherapy Sources | Paid under OPPS; separate APC payment. State Note: Values are displayed in fee schedule per APC values. |
| V | Clinic or Emergency Department Visit | Paid under OPPS; separate APC payment. State Note: Values are displayed in fee schedule per APC values. |
| X | Ancillary Services | Paid under OPPS; separate APC payment. State Note: No codes have Status Indicator of X. |
| Y | Non-Implantable Durable Medical Equipment | Not paid under OPPS. All institutional providers other than home health agencies bill to DMERC. State Note: Fee schedule currently incorporates the professional fee schedule amount or POC if not in professional schedule. |
4.23.6 Payment Modifiers for Outpatient Services – Hospital Outpatient and ASC. A modifier indicates that a service or procedure performed has been altered by some specific circumstance but has not changed its definition or code. The modifying circumstance shall be identified by the appropriate modifier following the procedure code. The 2-digit modifier should be placed after the usual procedure number. If more than 1 modifier is used, place the “Multiple Modifiers” code 99 immediately after the procedure code to indicate that additional modifier codes will follow. Place the additional modifiers after modifier 99. Only certain modifiers in each of the categories (Evaluation and Management, Anesthesia, Surgery, Pathology and Laboratory, Radiology, General Medicine, Physical Medicine, Hospital and Hospital Outpatient/ASC Services) will be recognized for reimbursement purposes. The following modifiers will be recognized for reimbursement by the fee schedule for Hospital Outpatient and ASC services codes:
25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service:It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note:This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.
27 Multiple Outpatient Hospital E/M Encounters on the Same Date:For hospital outpatient reporting purposes, utilization of hospital resources related to separate and distinct E/M encounters performed in multiple outpatient hospital settings on the same date may be reported by adding modifier 27 to each appropriate level outpatient and/or emergency department E/M code(s). This modifier provides a means of reporting circumstances involving evaluation and management services provided by physician(s) in more than 1 (multiple) outpatient hospital setting(s) (e.g., hospital emergency department, clinic). Note:This modifier is not to be used for physician reporting of multiple E/M services performed by the same physician on the same date. For physician reporting of all outpatient evaluation and management services provided by the same physician on the same date and performed in multiple outpatient setting(s) (e.g., hospital emergency department, clinic), see Evaluation and Management, Emergency Department, or Preventive Medicine Services codes.
50 Bilateral Procedure:Unless otherwise identified in the listings, bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate 5-digit code. State Note: This modifier should not be appended to designated "add-on" codes (see Appendix D (of CPT)).
State Note: There will be no reductions to the procedures billed with the modifier -50.
State Note: Procedures performed bilaterally are reported as 2 line items and modifier 50 is not appended. These codes are identified with CPT specific language at the code or subsection level. Modifiers RT and LT may be appended as appropriate.
52 Reduced Services:Under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note:For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use (of CPT)).
58 Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period:It may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure. Note:For treatment of a problem that requires a return to the operating/procedure room (e.g., unanticipated clinical condition), see modifier 78.
59 Distinct Procedural Service:Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note:Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.
State Note: There will be no reductions to procedures billed with modifier 59.
73 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia:Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general). Under these circumstances, the intended service that is prepared for but canceled can be reported by its usual procedure number and the addition of modifier 73. Note:The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.
74 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia:Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc.). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. Note:The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.
76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional:It may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service. Note:This modifier should not be appended to an E/M service.
77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional:It may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 77 to the repeated procedure or service. Note:This modifier should not be appended to an E/M service.
78 Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period:It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedures, see modifier 76.)
79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period:The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79. (For repeat procedures on the same day, see modifier 76.)
91 Repeat Clinical Diagnostic Laboratory Test:In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91. Note:This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.
E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper Right, eyelid
E4 Lower right, eyelid
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
FA Left hand, thumb
GG Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day
GH Diagnostic mammogram converted from screening mammogram on same day
LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LM Left main coronary artery
LT Left side (used to identify procedures performed on the left side of the body)
QM Ambulance service provided under arrangement by a provider of services
QN Ambulance service furnished directly by a provider of services
RC Right coronary artery
RI Ramus intermedius coronary artery RT Right side (used to identify procedures performed on the right side of the body)
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit
TA Left foot, great toe
4.24 Multiple Procedures for Professional and Facility Procedures
4.24.1 Multiple Procedure Reimbursement Rules. More than 1 procedure performed during the same operative session at the same operative site are reimbursed as follows:
4.24.2 Bilateral Procedure Reimbursement Rule
4.24.3 Multiple Procedure Billing Rules for Professional and Facility Procedures
4.25 Repair of Wounds
4.25.1 Definitions
The following words and terms, when used in19 DE Admin. Code 1341 and 1342 PART A-PART G, have the following meaning.
“Simple repair” means repair of superficial wounds involving primarily epidermis and dermis or subcutaneous tissues without significant involvement of deeper structures and simple 1 layer closure/suturing. This includes local anesthesia and chemical or electro cauterization of wounds not closed.
“Intermediate repair” means repair of wounds that requires layered closure of 1 or more of the subcutaneous tissues and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure. Single-layer closure of heavily contaminated wounds that require extensive cleaning or removal of particulate matter also constitutes intermediate repair.
“Complex repair” means repair of wounds requiring more than layered closure, scar revision, debridement (e.g., traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. It may include creation of the defect and necessary preparation for repairs or the debridement and repair of complicated lacerations or avulsions.
4.25.2 Reporting. The following instructions are for reporting services at the time of the wound repair:
4.26 Musculoskeletal System
4.26.1 Casting and Strapping. This applies to severe muscle sprains or strains that require casting or strapping.
4.26.2 Fracture Care
4.26.3 Arthroscopy.Note:Surgical arthroscopy always includes a diagnostic arthroscopy. Only in the most unusual case is an increased fee justified because of increased complexity of the intra-articular surgery performed.
4.26.5 External Spinal Stimulators Post Fusion. The following criteria are established for the medically accepted standard of care when determining applicability for the use of an external spinal stimulator.
4.26.6 Carpal Tunnel Release. The following intra operative services are included in the global service package for carpal tunnel release and should not be reported separately and do not warrant additional reimbursement:
4.27 Radiology
4.27.1 Payment Ground Rules for Diagnostic and Therapeutic Radiological Services
4.27.1.1 General Guidelines
4.27.1.2 Definitions and items unique to radiology are listed below:
4.27.1.3 Subject Listings. Subject listings apply when radiological services are performed by or under the responsible supervision of a physician.
4.27.1.3.5 Injection Procedure
4.27.2 Payment Modifiers for Diagnostic and Therapeutic Radiological Services
4.27.2.3 The following modifiers will be recognized for reimbursement by the fee schedule for diagnostic and therapeutic radiology services codes:
22 Increased Procedural Services:When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, and physical and mental effort required). Note: This modifier should not be appended to an E/M service.
26 Professional Component:Certain procedures are a combination of a physician or other qualified health care professional component and a technical component. When the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
50 Bilateral Procedure:Unless otherwise identified in the listings, bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate five-digit code. Note: This modifier should not be appended to designated "add-ons" (see Appendix D (of CPT)).
State Note: There will be no reductions to the procedures billed with the modifier 50.
State Note: Procedures performed bilaterally are reported as two line items, and modifier 50 is not appended. These codes are identified with CPT specific language at the code or subsection level. Modifiers RT and LT may be appended as appropriate.
52 Reduced Services:Under certain circumstances, a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of modifier 52 signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use (of CPT)).
53 Discontinued Procedure:Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifier 73 and 74 (see modifiers approved for ASC hospital outpatient use (of CPT)).
59 Distinct Procedural Service:Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier available, and use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.
State Note: There will be no reductions to procedures bills with modifier 59.
76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional:It may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service. Note:This modifier should not be appended to an E/M service.
77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional:It may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 77 to the repeated procedure or service. Note:This modifier should not be appended to an E/M service.
99 Multiple Modifiers:Under certain circumstances, 2 or more modifiers may be necessary to completely delineate a service. In such situations, modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service.
LT Left Side:Used to identify procedures performed on the left side of the body.
RT Right Side:Used to identify procedures performed on the right side of the body.
TC Technical Component Only:Certain procedures are a combination of a physician component and a technical component. When the technical component is reported separately by the physician or clinic, the service may be identified by adding modifier TC to the usual procedure number.
4.28 Laboratory and Pathology
4.28.1 Payment Ground Rules for Pathology and Laboratory Services
4.28.1.1 General Guidelines
4.28.1.5 Collection and Handling Procedures. Fees assigned to each test represent only the cost of performing the individual test, whether it is manual or automated (mechanized). The collection, handling, and patient administrative services have been assigned separate fees and separate code numbers.
4.28.1.6 Professional Component. The maximum allowable reimbursement (MAR) includes the professional component (PC) plus the technical component (TC) when performed by the physician or clinic. This value is applicable in any situation in which a single charge is made to include both professional services and the technical cost of providing that service.
4.28.1.10 Special Report. A service that is rarely provided, unusual, variable, or new may require a special report in determining medical appropriateness of the service. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure; and the time, effort, and equipment necessary to provide the service. Additional items that may be included are:
4.28.2 Payment Modifiers for Pathology and Laboratory Services
4.28.2.3 The following modifiers will be recognized for reimbursement by the fee schedule for pathology and laboratory codes:
22 Increased Procedural Services:When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, and physical and mental effort required). Note: This modifier should not be appended to an E/M service.
26 Professional Component:Certain procedures are a combination of a physician or other qualified health care professional component and a technical component. When the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
53 Discontinued Procedure:Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifier 73 and 74 (see modifiers approved for ASC hospital outpatient use (of CPT)).
59 Distinct Procedural Service:Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.
90 Reference (Outside) Laboratory:When laboratory procedures are performed by a party other than the treating or reporting physician or other qualified health care professional, the procedure may be identified by adding modifier 90 to the usual procedure number.
91 Repeat Clinical Diagnostic Laboratory Test:In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91. Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.
92 Alternative Laboratory Platform Testing:When laboratory testing is being performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable analytical chamber, the service may be identified by adding modifier 92 to the usual laboratory procedure code (HIV testing 86701-86703 and 87389). The test does not require permanent dedicated space; hence by its design it may be hand carried or transported to the vicinity of the patient for immediate testing at that site, although location of the testing is not in itself determinative of the use of this modifier.
99 Multiple Modifiers:Under certain circumstances, 2 or more modifiers may be necessary to completely delineate a service. In such situations, modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service.
TC Technical Component Only:Certain procedures are a combination of a physician component and a technical component when performed by physician or clinic. When the technical component is reported separately, the service may be identified by adding modifier TC to the usual procedure number.
4.29 Physical Medicine
4.29.1 Payment Ground Rules for Physical Medicine Services
4.29.1.1 General Guidelines
4.29.1.2 Initial Evaluation and Re-evaluation by Physical Therapists or Occupational Therapists
4.29.1.4 Manipulation Codes
4.29.2 Payment Modifiers for Physical Medicine Services
4.29.2.3 The following modifiers will be recognized for reimbursement by the fee schedule for physical medicine services codes:
22 Increased Procedural Services:When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, and physical and mental effort required). Note: This modifier should not be appended to an E/M service.
24 Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period:The physician or other qualified health care professional may need to indicate that an E/M service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.
26 Professional Component:Certain procedures are a combination of a physician or other qualified health care professional component and a technical component. When the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
52 Reduced Services:Under certain circumstances, a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of modifier 52 signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use (of CPT)).
53 Discontinued Procedure:Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use (of CPT)).
59 Distinct Procedural Service:Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.
99 Multiple Modifiers:Under certain circumstances, 2 or more modifiers may be necessary to completely delineate a service. In such situations, modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service.
4.30 Durable Medical Equipment and Supplies
5.4 An employer or insurance carrier may request utilization review by complying with all the terms and conditions set forth on the forms attached hereto. Upon completion and submission of the forms, information package and medical records package by the employer or insurance carrier, the designated utilization review company will review treatment to determine if it is in compliance with the practice guidelines developed by the Workers’ Compensation Oversight Panel and adopted and implemented by the Department of Labor. (See Appendix A)
5.4.4 In the instance of a compensable claim in which open surgery is recommended by the health care provider and stated by the provider to be within the applicable Practice Guideline, the following procedure may be followed by the operating surgeon to facilitate resolution of payment for such treatment:
5.4.4.1 The operating surgeon must specify the particular surgery to be performed and must certify in writing that:
5.5 The decision of the utilization review company shall be forwarded by the Department of Labor, by Certified Mail, Return Receipt Requested, to the claimant, the claimant’s attorney of record, the health care provider in question, and the employer or its insurance carrier.
5.5.2 If there are no current practice guidelines applicable to the health care provided, a party may file a petition with the Industrial Accident Board seeking a determination of the appropriateness of treatment.
APPENDIX A
DELAWARE DEPARTMENT OF LABOR
MEDICAL UTILIZATION REVIEW PROGRAM
REQUEST FOR UTILIZATION REVIEW
(Pursuant to19 Del.C. §2322 F(j))
PLEASE TYPE OR CLEARLY PRINT ALL INFORMATION. All information and addresses must be verified as current and accurate.
4. Claimant's Name_________________________________________________________________
Age______ Sex______
Address___________________________________________Tel. No._______________________
City______________________________________________ State_______ Zip______________
6. Party Requesting Review __________________________________________________________
Primary Contact at Party's Office_____________________________________________________
Email Address___________________________________________________________________
Address___________________________________________ Tel. No.______________________
City______________________________________________ State________ Zip______________
7. Name of Claimant's Attorney _______________________________________________________
Address _______________________________________________________________________
8(a). Health Care Provider to be Reviewed________________________________________________
Specialty (if applicable)____________________________________________________________
Date of first treatment _____________________________________________________________
Address___________________________________________ Tel. No.______________________
City______________________________________________ State_______ Zip_______________
8(b). Health Care Provider to be Reviewed________________________________________________
Specialty (if applicable)____________________________________________________________
Date of first treatment _____________________________________________________________
Address___________________________________________ Tel. No. ______________________
City______________________________________________ State_______ Zip_______________
8(c). Additional Health Care Providers to be reviewed (list name, specialty, address, etc. on a separate sheet)
8(d). Health Care Facility Impacted (e.g. hospital, ambulatory surgery center, etc.) by this retrospective review (list name, address, etc. on a separate sheet)
9. Treatment to be reviewed: Specify the health care service to be reviewed and the timeframe within which the treatment was or will be rendered.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
My signature certifies the following: (a) all names and addresses on this form have been verified as current and accurate; (b) two identical copies of associated medical material are being submitted for review; (c) the bill denial for the treatment subject to this review was sent within 30 days of receiving the provider's bill; and (d) all items listed in the table of contents are in each copy of the medical material.
__________________________________ ______________________________________
Print Name of Requester Signature of Requester
COPY THIS FORM OR REPRODUCE EXACTLY IN APPEARANCE AND CONTENT.
SEE INSTRUCTIONS ON BACK
FOR REQUIRED CONTENT, PRESENTATION AND BINDING METHOD
FOR ALL MATERIALS SUBMITTED FOR UTILIZATION REVIEW
In accordance with19 Del.C. §2322 F(j) and the regulations adopted pursuant thereto, all information and medical records submitted to the Department of Labor, Office of Workers' Compensation must represent all of the facts of this case.
INFORMATION PACKAGE · REQUIRED CONTENT
"Completed and signed Request for Utilization Review Form.
If applicable, a list containing 1) names, addresses, etc. of the health care facilities impacted by this review; and 2) additional health care providers under review.
"Proof of date of issuance of claim denial (so the Department of Labor is able to verify that Utilization Review was requested within 15 days of the date of the claim denial).
MEDICAL RECORDS PACKAGE· REQUIRED CONTENT
Section 1. All reports, notes, etc., from provider being reviewed from the date of injury or the 2 year period immediately preceding the treatment to be reviewed, whichever is shorter, and the time frame within which the treatment to be reviewed was or will be rendered, as submitted to the requesting party.
Section 2. All reports, notes, etc., of other treating providers from the date of injury or the 1 year period immediately preceding the treatment to be reviewed, whichever is shorter, as submitted to the requesting party.
Section 3. All diagnostic test results from the date of injury or the 2 year period immediately preceding the treatment to be reviewed, whichever is shorter, as submitted to the requesting party.
NOTE Do not include copies of any billing statements or comments/instructions directed to the Utilization Review panel. All material must be presented in identified sections; each section's content must be presented in chronological order.
REQUIRED PRESENTATION AND BINDING METHOD FOR ALL SUBMITTED MATERIALS
b. If tabs are used for the sections, they must be positioned to the right side of the document.
Mail or Deliver to: Department of Labor
Office of Workers' Compensation
4425 N. Market St.
Wilmington, DE 19802
302-761-8200
2. If submitting electronically:
Email tohcpaymentquestions@delaware.gov
6.2 The Physicians Report of Workers' Compensation Injury "Progress"
Report and Instructions (Physicians Form) and complete instructions on completing the form will be available on the Department of Labor web site.