1.4 Medical Restoration Services

The practitioner shall provide a written treatment plan prior to beginning physical restoration services. The complexity of the treatment plan will vary depending on the type of services being provided and may include services provided by other practitioners. The plan may be a stand- alone document, or it may be articulated in the “recommendations” section of a diagnostic report. Any treatment plan must identify the treatment objectives and parameters of proposed treatment in sufficient detail to enable DVR to authorize goods and services in advance, including the required services, length of treatment, scope and intensity of required procedures, and the anticipated follow-up. The treatment plan must reflect that all restoration services are likely to correct or substantially improve an impairment that constitutes a substantial impediment to employment within a reasonable period (time-limited —not ongoing) and are essential to achieving the employment outcome.

Surgical services will only be provided when certified as medically necessary by the attending physician. Routine surgical supplies and incidental procedures commonly carried out as an integral part of the surgical service are considered part of the treatment protocol and do not warrant separate payment. However, multiple surgical procedures and occasions when the skills of more than one surgeon are necessary the following may apply.

Multiple procedures during one surgery

• Multiple surgical procedures performed with a single surgical incision, regardless of how many organ systems are involved or how many different surgeons participated, indicated by a modifier of 51 for the second and subsequent procedures:

  • 100% of the relative value for the procedure commanding the greatest value;

  • 50% of the relative value for the second procedure; and

  • 25% of the relative value for each subsequent procedure.

  • Microsurgery is 125% of the relative value for the surgical procedure unless the CPT code already specifies that the procedure involve microsurgery.

• Bilateral surgical procedures performed by one surgeon, indicated by a modifier code of 50:

  • 100% of the relative value for the first procedure;

  • 80% of the relative value for the second procedure.

• Multiple surgical procedures requiring two or more incisions (separate organ systems or different anatomical locations), indicated by a modifier of 51 for the second and subsequent procedures:

  • 100% of the allowable value for the first procedure: and

  • 70% of the allowable value for each subsequent procedure.

Procedures performed by multiple surgeons

• Two primary surgeons involved in the performance of a single surgical procedure, indicated by a modifier of 62:

  • 125% of the procedure's relative value, split equally between the surgeons.

  • Bilateral surgical procedures or multiple procedures involving different organs or body systems performed by two surgeons, indicated by a CPT modifier code of 50:100% of the relative value for both procedures

• Services of an assistant surgeon

  • Indicated by modifier codes 80 or 82: 20% of the relative value

  • Indicated by modifier code 81: 10% of the relative value

(Procedure codes 11300-01, 11300-02)

Laboratory and X-ray services are performed as part of a treatment plan to treat conditions with specific symptoms. They are not typically routine diagnostic tests performed without apparent relationship to a specific illness, symptom, complaint, or injury. A licensed physician must authorize all laboratory and X-ray services. The services must be provided by a physician’s office or by the physician’s clinical laboratory that is certified in accordance with the Clinical Laboratory Improvement Amendments of 1988 or meets the Health Care Financing Administration guidelines; or by an independent laboratory certified by the Health Facilities Division of the Colorado Department of Public Health and Environment.

CPT codes for laboratory services are found in the "Radiology" and "Pathology" sections of the RVP. The fees for radiological diagnostic procedures are frequently separated into two components. The "technical component" (TC) covers the cost of equipment, supplies, technical personnel, and other incidental expenses. This component is allowed when the service is provided to an outpatient by an appropriately certified laboratory. Payment is allowed for a "professional component" (modifier 26) to compensate the radiologist for supervision of the laboratory's activities and interpretation of the radiological studies, when required. Alternatively, both components can be billed in total with a modifier of 00.

In addition, the CPT coding structure lists tests in groups at a lower cost than individual tests. When tests are ordered in a group, the individual tests will not be paid separately. Conversely, when the physician orders multiple individual tests that can be performed in a group, the maximum-allowable fee corresponds to the CPT code for such tests in a group. Laboratory procedures are generally found in the “Radiology” or “Pathology and Laboratory” sections of the RVP.

Laboratory services provided to hospital patients under the supervision of the hospital are considered part of the hospital's treatment facility services and a separate payment is not warranted. Tests performed by an independent certified lab are purchased separate from the associated treatment procedures.

(Procedure codes 11400-02, 11500-01, 11600-01, 11700-01)

Treatment procedures found in the “Medicine” section of the RVP (CPT codes 97010-97799) are typically performed by physical and occupational therapists. The need for such services must be included as part of a treatment plan and must be authorized by a licensed physician.

(Procedure code 11700-01 or 11500-01, provided by physical therapist)

Certified massage therapists may provide massage therapy when authorized as part of a treatment plan by a licensed physician. Services provided by massage therapists are limited to CPT code 97124 and are paid at 50% of the procedure's relative value.

(Procedure code 11700-01- “Other Therapy”)

Licensed acupuncturists may provide acupuncture services when authorized as part of a treatment plan by a licensed physician. Services provided by acupuncturists are limited to CPT codes 97810 through 97814 and paid at 100% of the procedure’s relative value.

(Procedure codes 11900-01, 11900-02, 11900-03)

Home health services consist of skilled nursing services and home health aide services. They must be provided by a home health agency, certified by the Department of Health Care Policy and Financing. Home health aide services must include at least one task defined as skilled personal care under the direct direction and supervision of an appropriately licensed nurse. Payment for home health services is on a per visit basis, regardless of the number of nurses or nurse aides in attendance, for up to 2 ½ hours.

A “visit” means a personal contact made by a nurse or home health aide with the individual in the individual's place of residence for the purpose of providing a legitimate home health service. The cost of supplies used by home health agency staff for universal precautions is included in the payment for each visit. Other supplies are paid for separately. Home health services will be paid at the rates identified below or the actual amount invoiced charge, whichever is less.

• Nursing Visit - $95.79 per visit

• Home Health Aide Visit - $39.67 for first hour and $9.46 for each additional half hour