Standardized Billing Form

Any insurance company, employer, or other payer who reduces or denies charges from a provider according to the general instructions, ground rules, or maximum fees contained within this fee schedule must show the specific basis of the reduction or denial by use of an "Explanation of Benefits" form. The specific general instruction, specific ground rule, or specific maximum fee that was used for the reduction or denial must be indicated or identified. When payment is reduced or denied on some other basis, the "Explanation of Benefits" form must contain a complete explanation as to why, for example, the service was unreasonable, the service was more appropriately defined by another procedure code, or the service was not related to a compensable injury. When any such reduction or denial occurs, the "Explanation of Benefits" form shall also include: 1) the identity of the person or entity that made the decision for the reduction or denial; 2) the identity of the person or entity that is ultimately responsible for payment; and 3) the telephone number of such person or entity where further explanation of the reduction or denial can be obtained. In the event a controversy arises between the provider and the payer, an attempt should be made by the involved parties to resolve said issue(s). Issues which cannot satisfactorily be resolved should then be referred to the Director of Workers Compensation for review.

As a further attempt to avoid controversy arising between the provider and the payer for failure to make timely payment for any medical services provided, it is recommended that the insurance company or self-insured employer make payment for any medical services that were provided either: 1) within 30 days of receiving the bill submitted and any necessary documentation required by the fee schedule, or; 2) within 30 days of it being determined that the medical service provided is the result of an injury that is compensable under the Workers Compensation Law.

SPECIAL NOTE: The five-digit codes included in this Schedule of Medical Fees (with the exception of the Dentistry Section and the Durable Medical Equipment and Supplies Section) are obtained from 2014 Current Procedural Terminology (CPT), copyright 2013 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five-digit codes and modifiers for reporting medical services and procedures performed by physicians.  

The responsibility for the content of the Schedule of Medical Fees is with the state of Kansas Division of Workers Compensation and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in the Schedule of Medical Fees. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside of Workers Compensation Schedule of Medical Fees, should require reference to the most recent publication of the AMA Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms.

Schedule of Medical Fees

The Kansas Workers Compensation Schedule of Medical Fees has utilized portions of the following documents:

1. The Current Procedural Terminology, Fourth Edition, copyright 2014 (a.k.a. CPT 2013) by the American Medical Association 

2. The CDT(Current Dental Terminology) Companion, CDT-2013/2014, copyright 2012, published by the American Dental Association 

3. The 2014 Relative Value Guide, copyright 2012, developed by the American Society of Anesthesiologists 

4. The 2014 Essential RBRVS, a comprehensive listing of RBRVS values for CPT and HCPCS Codes, copyright 2013 Ingenix.

5. The January 2014 HCPCS allowances that were obtained from the DMEPOS Fee Schedule of the Centers for Medicare & Medicaid Services (CMS). 

6. Medicare Severity Diagnosis Related Groups (MS-DRGs) Definitions Manual, Version 31.  

Some of the most important revisions that have been utilized within this Schedule of Medical Fees are as follows:

1. The Conversion Factors for all CPT codes in the Medicine and Evaluation and Management Sections have been increased by 3%. 

2. ICD-10 is not mandated by Kansas Workers Compensation. However, it is strongly recommended that ICD-10 be employed for billing purposes on the CMS 1500 Form or an equivalent form containing the same information. 

3. Surgical CPT code 36415 has been moved to the Pathology and Laboratory Section of the fee schedule. 

4. Trauma Alerts in Ground Rule 7 of Inpatient Hospital and Ground Rule 4 of Ambulatory Surgical Centers/Hospital Outpatient are increased by 7%.

5. Compound drugs and physician dispensed medications shall be reimbursed the same as pharmacies based on the original manufacturer NDC but must be preapproved by the payer. 

6. An inpatient stay requires documentation of official admission to the hospital pursuant to an order for inpatient admission by a physician or other qualified practitioner and the order must be present in the medical record.   

Billing for Audiology Services

Audiology services may not be billed when the place of service is a comprehensive outpatient rehabilitation facility (CORF) or a rehabilitation agency.

Audiology services may be furnished and billed by audiologists and, when these services are furnished by an audiologist, no physician supervision is required. 

The interpretation and report shall be written in the medical record by the audiologist, physician, or NPP who personally furnished any audiology service, or by the physician who supervised the service. Technicians shall not interpret audiology services, but may record objective test results of those services they may furnish under direct physician supervision.

Payment for the interpretation and report of the services is included in payment for all audiology services, and specifically in the professional component if the audiology service has a professional component/technical component split.

1. Billing under the MPFS for Audiology Services Outside the Facility Setting 

The individuals who furnish audiology services in all settings must be qualified to furnish those services. The qualifications of the individual performing the services must be consistent with the number, type and complexity of the tests, the abilities of the individual, and the patient’s ability to interact to produce valid and reliable results. The physician who supervises and bills for the service is responsible for assuring the qualifications of the technician, if applicable are appropriate to the test.

a. Professional Skills. 

When a professional personally furnishes an audiology service, that individual must interact with the patient to provide professional skills and be directly involved in decision-making and clinical judgment during the test.

The skills required when professionals furnish audiology services for payment under the MPFS are masters or doctoral level skills that involve clinical judgment or assessment and specialized knowledge and ability including, but not limited to, knowledge of anatomy and physiology, neurology, psychology, physics, psychometrics, and interpersonal communication. The interactions of these knowledge bases are required to attain the clinical expertise for audiology tests. Also required are skills to administer valid and reliable tests safely, especially when they involve stimulating the auditory nerve and testing complex brain functions. 

Diagnostic audiology services also require skills and judgment to administer and modify tests, to make informed interpretations about the causes and implications of the test results in the context of the history and presenting complaints, and to provide both objective results and professional knowledge to the patient and to the ordering physician

Examples include, but are not limited to:

• Comparison or consideration of the anatomical or physiological implications of test results or patient responsiveness to stimuli during the test; 
• Development and modification of the test battery and test protocols; 
• Clinical judgment, assessment, evaluation, and decision-making; Interpretation and reporting observations, in addition to the objective data, that may influence interpretation of the test outcomes; 
• Tests related to implantation of auditory prosthetic devices, central auditory processing, contralateral masking; and/or  
• Tests to identify central auditory processing disorders, tinnitus, or nonorganic hearing loss

Audiology codes may be billed under the MPFS by audiologists, physicians, and NPPs using their own NPI in the rendering loop when those professionals personally furnish the test. Physicians and NPPs may not bill for these codes when an audiologist has furnished the service