REGULATORY ACTIVITY:

• WSI reimburses for vision correction materials (e.g. eyeglasses, contact lenses) when prescribed and deemed appropriate for an accepted workers’ compensation claim. The following are circumstances under which WSI may reimburse for vision correction materials:
  • A work injury causes damage to existing vision correction materials requiring replacement
  • Vision correction materials become necessary to correct an impairment caused by a work injury
  • Replacement vision correction materials are necessary to continue the correction of an impairment caused by a work injury.

 A provider must obtain prior authorization prior to dispensing vision correction materials. The request for approval must include all add-on features, whether optional or prescribed.  To request prior authorization, a provider may contact the claims adjuster by calling WSI’s Customer Service Department at 701-328-3800 or 800-777-5033. Reimbursement for vision correction materials is issued per the WSI Fee Schedule. When a work injury causes damage to existing vision materials, WSI may issue a one-time reimbursement in full to replace the exact features present prior to the damage. A provider may not bill the patient, employer, or another insurer for the balance of a paid or denied charge. For cosmetic or functional features not necessary to treat a work injury, a provider may utilize the Advanced Beneficiary Notice (ABN) form. The ABN form should provide the estimated costs for each elective feature and allows an injured worker to accept financial responsibility. When a signed ABN form is in place, a provider should append modifier -GA to the applicable line item(s) and attach the ABN form to the medical bill. WSI requires a provider submit charges for vision correction materials with the applicable HCPCS codes on a CMS-1500 form or via EDI. Charges submitted to WSI on an invoice are not eligible for reimbursement. For complete information on WSI’s billing options, a provider should visit the Billing/Payment section of the WSI website.

FEE SCHEDULE NEWS:

• WSI has released updates to the following fee schedules with an effective date of January 1, 2019: Ambulance, Anesthesia, APC, Ambulatory Surgical Center, Durable Medical Equipment, Inpatient Hospital, Clinical Laboratory, Medical Provider Fee Schedule, Outpatient Hospital and Physician Drugs. The next expected update to the fee schedules is April 1, 2019.

REGULATORY ACTIVITY:

• Effective for dates of service on and after January 1, 2019, WSI has implemented a new code, W0420, for a provider to bill when instructing an injured worker on the use of a TENS unit. The W0420 code replaces code 64550 (Application of surface neurostimulator), which was deleted from the Current Procedural Terminology (CPT®) codebook for 2019. When a provider bills a W0420 code, WSI requires written documentation regarding instruction on the TENS unit to accompany the bill. The reimbursement amount for W0420 in 2019 is $20.00. Reimbursement for WSI for TENS instruction is in addition to any reimbursement offered by the TENS supplier. The following is a reminder of the standard process involving the prescription for a TENS unit: The treating provider submits an Electro Medical Device Certification Request (M5) form, along with a prescription for a TENS unit to WSI. WSI reviews the request for medical necessity. If the request is approved, CPR Medical coordinates mailing of the TENS unit to the appropriate party, i.e. rendering provider or directly to the injured worker. WSI reimburses CPR Medical for the TENS unit. CPR Medical may offer a voucher to the rendering provider to instruct the injured worker on use of the TENS unit. To view this notice, go to http://www.workforcesafety.com/news/news-item/change-in-billing-for-instruction-on-the-use-of-a-transcutaneous-neurostimulator-tens-unit.

REGULATORY ACTIVITY:

• WSI recently published an article about the Advanced Beneficiary Notice (ABN) process. After receiving several follow-up questions from providers about the article, WSI is providing further clarification.  To view the published clarification, go to http://www.workforcesafety.com/news/news-item/clarification-on-previous-advanced-beneficiary-notice-abn-article.
• Effective January 1, 2019, WSI will implement fee schedule changes. To view the notice and a summary of the changes, go to http://www.workforcesafety.com/news/news-item/updated-fee-schedule-effective-january-1-2019.  To view the complete set of fee schedules for North Dakota, go to  http://www.workforcesafety.com/WSI/billingfeeschedule/FeeSchedule/FeeSchedule

REGULATORY ACTIVITY:

• November 2018: Workforce Safety and Insurance (WSI) requires a provider to complete the Advanced Beneficiary Notice of Non-Coverage (ABN) form for each individual date of service.  When recommending a medical service that WSI may not allow, the ABN informs the injured worker of the estimated cost for the service.  This allows the injured worker to decide whether to receive the service and accept financial responsibility if WSI denies payment. To identify a charge accompanied with a signed ABN, a provider should append modifier -GA to each applicable bill line.  A provider should then submit the signed ABN along with the bill and medical documentation to WSI.  WSI will review for the most appropriate payment determination.  If WSI does not reimburse for the service, a provider may then bill an injured worker or other insurance as specified by WSI's remittance advice reason codes. If you have questions about this article, please send an email to wsipr@nd.gov.  To view this notice, go to http://www.workforcesafety.com/news/news-item/advanced-beneficiary-notice-abn-form-to-be-completed-for-each-date-of-service.

FEE SCHEDULE NEWS:

• The following WSI fee schedules have been updated as of October 1, 2018: APC, Ambulatory Surgery, Clinical Lab, Physician, Outpatient Hospital and Physician Drug Module. The next update is expected January 2019.

REGULATORY ACTIVITY:

• To establish claim and medical bill liability, WSI requires a provider submit a specific diagnosis code reflective of the injury treated. This requirement aligns with General Coding Guidelines (4) and (18), published in the ICD-10-CM Official Guidelines for Coding and Reporting. These General Coding Guidelines indicate: "Specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition…. Diagnosis codes describing symptoms and signs are acceptable for reporting only when the provider has not established a related, definitive (confirmed) diagnosis.” WSI most commonly encounters improper diagnosis coding when a provider assigns a standalone diagnosis code of “pain”, and the medical record indicates a more specific diagnosis is available. While pain may be a relevant sign or symptom resulting from a work injury, it is not a specific condition for which WSI accepts liability. Consequently, receipt of a service coded with “pain” as the only diagnosis may result in a prolonged claim adjudication timeframe as well as a bill reimbursement denial. The following is an example of reporting a diagnosis with the highest level of specificity: WSI receives a medical bill with attached documentation for an initial visit following a work injury. The worker was lifting a box when they felt something pull in their lower back, followed by aches and pains. The signs and symptoms reported in the medical record include muscle swelling over the lumbar region. The diagnosis indicated in the medical record and reported on the medical bill is M54.5 for lumbar pain. A more appropriate diagnosis, based on the evidence in the medical record, would be S39.012 for a low back strain.
• It has come to our attention that fraudulent checks using our name are being mailed in FedEx packages, falsely representing payment from Workforce Safety & Insurance, (WSI).  Typically, WSI does not mail checks via FedEx.  If you have received a check from WSI in a FedEx envelope, the check is likely a fake check.  If you want to clarify if a check you received from WSI is valid, you may call WSI Customer Service at 1-800-777-5033.  The bulk of these payments are being sent to pay for online purchases. The check payment total is significantly more than the purchase price of the item you are selling, and the buyer requests you to send the excess funds back to them or they will have someone stop by and pick them up. Your bank may accept these checks when you deposit them.  However, when the check is presented to the issuing bank, it will be declined and returned to your bank.  At that time, your bank will make you responsible for the funds if the check you deposited is a fake check. WSI is not affiliated with these checks.
• WSI has expanded the EDI billing options available through iHCFA to include facility charges (UB-04/837i). Prior to this, WSI had implemented the electronic submission of professional charges (CMS 1500/837p) only.  For both types of billing (837p and 837i), submission through iHCFA is available at no cost to the provider.
• iHCFA is a specialized clearinghouse that facilitates the electronic submission of bills, medical reports, and supporting documents to workers' compensation payers.  Use of this billing option provides several benefits not accessible for paper billing, including automated attachment of a medical record to a bill, confirmation reports of bill receipt, and improved bill payment timeframes.

iHCFA provides the following options for submitting medical bills electronically:

• Direct connection with WSI for medical bill and documentation submission
• Online claim form interface, including documentation attachment
• Indirect connection with a provider’s existing clearinghouse, dependent on the clearinghouse’s ability to meet certain technical requirements

A provider interested in submitting EDI medical bills must register with both WSI and iHCFA.

• To register with WSI, complete the Payee Registration and Substitute W-9 form and fax to 888-786-8695.
  • This step is applicable for a new or existing billing provider who wishes to begin EDI billing.
  • A provider must complete this form for each business NPI billed to WSI.
  • Alternatively, a provider may submit the form for one business NPI and include an attachment. The attachment must provide the details requested on the form for each additional NPI.
• To register with iHCFA, or for additional information, contact iHCFA at 973-795-1641 (option 2)

REGULATORY ACTIVITY:

• Effective September 1, 2018, WSI will require prior authorization for non-emergent air transportation services, see North Dakota Administrative Code 92-01-02-34.5(e). To request prior authorization, a provider must complete the Non-Emergent Air Ambulance Facility-to-Facility Request form and submit to WSI along with supporting medical documentation. WSI will notify the requesting provider of the authorization status within 24-hours, or by the end of the next business day. To facilitate safe and cost-effective air transportation for injured workers, WSI has established Memorandums of Understanding (MOUs) with several air transportation companies. Companies with current MOUs include Bismarck Air Medical, Trinity Health System, and TravelAire. It is WSI's expectation a provider will utilize these companies for non-emergent air transportation services. If you have questions about this article, please send an email to wsipr@nd.gov.
• Effective October 1, 2018, WSI will implement a change to the window period allowed in the existing chiropractic pilot program. The pilot program currently requires a chiropractor to obtain authorization for all chiropractic treatment extending beyond the initial 6 visits.  Based on pilot program analysis and provider feedback, WSI will alter the program to extend the window period from 6 visits to 10 visits.
• WSI defines the window period as a period of initial chiropractic treatment on a claim not requiring prior authorization.  For initial treatment with a date of service on or after October 1, 2018, each claim will have one window period, which will include:
  • 10 visits or 60 days of care, whichever comes first, including initial evaluation
  • Treatment of all body parts accepted on a claim
  • Up to two modalities per visit

For treatment occurring outside the window period, a chiropractor will need to complete the Utilization Review Chiropractic (UR-Chiro) form.  For window periods beginning prior to October 1, all treatment provided after the sixth visit will require prior authorization. For window periods beginning on or after October 1, all treatment provided after the tenth visit will require prior authorization. WSI will continue to require prior authorization for all palliative care. If you have questions about this article, please send an email to wsipr@nd.gov.  To view this announcement, go to http://www.workforcesafety.com/news/news-item/change-to-chiropractic-window-period.  A copy of the form is attached.

REGULATORY ACTIVITY:

• July 2018:  WSI recently partnered with Cordant Health Solutions to assist in the coordination of medication monitoring for injured workers on chronic opioid therapy. Monitoring of drug testing is a component of WSI’s Chronic Opioid Therapy medical policy. The services provided by Cordant Health Solutions replace those previously managed by Ameritox Ltd. The following is an overview of the process for medication monitoring pertaining to chronic opioid therapy: Cordant Health Solutions analyzes WSI’s pharmacy data to identify injured workers who have been on opioid therapy for 90 consecutive days for treatment of pain. Cordant Health Solutions contacts the WSI claims adjuster to request authorization to coordinate drug testing for an injured worker meeting the criteria listed above. The WSI claims adjuster reviews the identified injured worker’s file to assess the need for drug testing. Factors taken into consideration of this decision include whether WSI has record of previous drug testing, and if so, the date, type and scope of the testing. If the WSI claims adjuster approves drug testing, Cordant Health Solutions contacts the last prescriber of record to collect information on current medications and inquire about the next upcoming visit. Cordant Health Solutions sends a laboratory kit with collection instructions to the prescriber. A provider may bill WSI for collection using CPT® code 99000. Cordant Health Solutions sends results of the drug testing to both the prescriber and WSI. Cordant Health Solutions performs definitive testing to quantify the presence of prescribed, non-prescribed and illicit drugs in all samples. A provider may utilize laboratory services other than Cordant Health Solutions to conduct drug testing. However, it is WSI’s expectation the testing is comparable in type and scope, i.e. a provider must conduct definitive testing for prescribed, non-prescribed, and illicit drugs. The announcement may be viewed at http://www.workforcesafety.com/news/news-item/introduction-of-cordant-health-solutions-for-chronic-opioid-monitoring.

FEE SCHEDULE NEWS:

• The state has adopted changes to the APC, ASC, Dental, DME, Clinical Laboratory, Medical Provider Fee Schedule, Outpatient and Physician Drug modules with an effective date of July 1, 2018. The next update is expected in October 2018.

REGULATORY ACTIVITY:

• Department of Labor and Regulation:  Division of Insurance: (May 29, 2018) intends to amend rules to update the sources referenced in rule, and the definition of “health organization” to include “hospital.”  The general authority for these rules, as cited by the department, is SDCL §§ 58-3-11, 58-3-26, 58-4-48, 58-6-75, 58-26-13.1, 58-26-45.1,  58-26-46, 58-27-7, and 58-27-108.  A public hearing was held in the West River Conference Room, 124 South Euclid Avenue, 2nd Floor, Pierre, South Dakota, on June 18, 2018, at 2:00 p.m. CT. Copies of the proposed rules may be obtained without charge from and written comments sent to South Dakota Division of Insurance, Administrative Rules, 124 S. Euclid Avenue, 2nd Floor, Pierre, SD 57501. Electronic copies are also available by email to mallori.barnett@state.sd.us, and online at   https://dlr.sd.gov/insurance/admin_rules/public_hearings.aspx.  The comment period will remain open for ten days following the public hearing and will close on June 28, 2018.

FEE SCHEDULE NEWS:

• The state has adopted quarterly fee schedule updates with an effective date of April 1, 2018. The next scheduled update is expected in July 2018.

REGULATORY ACTIVITY:

• Published a notice regarding services not reimbursable by WSI.  WSI does not provide reimbursement for services considered unnecessary to treat or diagnose a compensable work injury.  This includes services generally considered preventive.  Below are some examples of the services billed to WSI in error. Services unnecessary to treat a work injury may include:
  • Treatment for communicable diseases (e.g. common cold),
  • Treatment for seasonal disorders (e.g. allergies), and
  • Treatment for pre-existing conditions (e.g. diabetes).
  • Services generally considered preventive: Flu vaccine, Mammogram and Pap smear.

There are circumstances in which a provider may render one or more of these services concurrently with the treatment of a work injury.  If this should occur, a provider should not bill WSI for the services unrelated to the work injury.  For these services, it is appropriate for a provider to pursue direct reimbursement from the patient or other insurance.

• Published a notice regarding expectations for presumptive drug screens and definitive drug testing.  WSI has expectations for presumptive drug screening and definitive testing, based on adopted medical guidelines. Reimbursement for these drug tests is dependent upon a provider’s compliance with these expectations. Non-compliance with the expectations may affect the reimbursement of other medical services.  Drug screens and testing are important to the claim management process as they are helpful in evaluating the following: Worker is taking prescribed medications that are at or below therapeutic or toxic levels (therapeutic drug monitoring); or Worker is taking prescribed controlled substance medications; or Worker is taking non-prescribed or illicit drugs. The two main methods of drug testing include initial qualitative (presumptive) screenings and confirmatory quantitative (definitive) testing. Presumptive screenings are either laboratory-based or point of collection (POC) testing, and drugs are reported as only either present or absent. Definitive tests are highly sensitive and specific to a particular drug(s) or class of drugs. There are many limitations of presumptive drug screenings, which necessitate the use of definitive testing for certain circumstances. The Work Loss Data Institute’s Official Disability Guidelines (ODG), adopted by WSI, details the following on when to perform definitive testing: “When the POC screen is appropriate for the prescribed drugs without evidence of non-prescribed substances, confirmation is generally not required.  Confirmation should be sought for (1) all samples testing negative for prescribed drugs, (2) all samples positive for non-prescribed opioids and (3) all samples positive for illicit drugs.” It is WSI’s expectation that a provider will perform presumptive screening when medically necessary and prior to any definitive testing. In addition, WSI expects definitive testing on all samples positive for non-prescribed opioids and all samples positive for illicit drugs. Failure, neglect, or refusal to respond to requests by WSI for drug testing may result in the denial of reimbursement for medical services provided. See North Dakota Administrative Code § 92-01-02-31.5(c). WSI follows CMS standards for the billing of drug screens and testing services.  A provider may bill one presumptive drug screening code (CPT 80305-80307) per day. In the event of a positive presumptive drug screen, a provider may bill one definitive drug testing code (CPT G0480-G0483) per day.
• Has published new reimbursement schedules that become effective April 1, 2018.  The published documents are for APC, Ambulatory Surgical Center, Durable Medical Equipment, Medical Provider Fee Schedule, Outpatient Hospital and Physician Drug.  To view the published documents, go to https://www.workforcesafety.com/WSI/billingfeeschedule/FeeSchedule/FeeSchedule

REGULATORY ACTIVITY:

• Posted notice of amendments to their workers' compensation rules that become effective on January 1, 2018.  The impacted rules include   92-01-02-02.5 Contributing Cause of Mental or Psychological Condition Defined; 92-01-02-13.1 General Contractors; 92-01-02-23.2  Employers to Provide Security Instrument; 92-01-02-11.1 Attorney’s Fees; and 92-01-03-02 Definitions.