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Workers' compensation -- HIPAA 835 Health care claim payment/remittance advice



5221.0100 Definitions

Subpart 1. Scope. The following terms have the meanings given in this chapter unless the context clearly indicates a different meaning.

Subp. 1a. Ambulatory surgical center. Ambulatory surgical center" means a distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and is accredited by Medicare or is an outpatient surgical center as defined in part 4675.0100, subpart 8, and licensed by the Minnesota Department of Health.

Subp. 1b. Appropriate record. "Appropriate record" is a legible medical record or report which substantiates the nature and necessity of a service being billed and its relationship to the work injury.

Subp. 2. Bill or billing. "Bill" or "billing" means a provider's statement of charges and services rendered for treatment of a work related injury.

Subp. 3. Charge. "Charge" means the payment requested by a provider on a bill for a particular service. This chapter does not prohibit a provider from billing usual and customary charges which are in excess of the amount listed in the fee schedule.

Subp. 4. Code. "Code" means the alphabetic, numeric, or alphanumeric symbol used to identify a specific health care service, place of service, or diagnosis as follows:

A. "Billing code" means a procedure code as defined in item F plus any applicable modifiers as defined in subpart 10a. A billing code is used to identify a specific health care service, article, or supply for billing purposes.

B. "CPT code" means a numeric code included in the Current Procedural Terminology Coding System manual, incorporated by reference in part 5221.0405, item D. A CPT code is used to identify a specific medical service, article, or supply.

C. "HCPCS code" means a numeric or alphanumeric code included in the Centers for Medicare and Medicaid Services' Common Procedure Coding System. An HCPCS code is used to identify a specific medical service, article, or supply. HCPCS level I codes are the numeric CPT codes listed in the CPT manual, incorporated by reference in part 5221.0405, item D. HCPCS level II codes are alphanumeric codes created for national use. HCPCS level II codes are listed in the HCPCS manual, incorporated by reference in part 5221.0405, item E.

D. "ICD-9-CM code" means a numeric code included in the International Classification of Diseases, Clinical Modification manual, incorporated by reference in part 5221.0405, item A. An ICD-9-CM code is used to identify a particular medical or chiropractic diagnosis.

E. "Place of service code" means the code used to identify the type of facility and classification of service as inpatient or outpatient service on the CMS 1500 claim form or the Uniform Billing Claim Form (UB-92 CMS 1450), incorporated by reference in part 5221.0405, items B and C.

F. "Procedure code" means a numeric or alphanumeric code used to identify a particular health care service. Procedure codes used in this chapter include CPT codes, HCPCS codes, revenue codes, dental codes, and codes in the National Drug Code Directory (NDC).

G. "Revenue code" means a numeric or alphanumeric code included in the UB-92 manual, incorporated by reference in part 5221.0405, item G. Revenue codes are used in institutional settings such as hospitals to identify an individual or group of medical services, articles, or supplies.

Subp. 5. Commissioner. "Commissioner" means the commissioner of the Department of Labor and Industry.

Subp. 6. Compensable injury. "Compensable injury" means an injury or condition for which a payer is liable under Minnesota Statutes, chapter 176.

Subp. 6a. Conversion factor. "Conversion factor" means the dollar value of the maximum fee payable for one relative value unit of a compensable health care service delivered under Minnesota Statutes, chapter 176.

Subp. 6b. Division. "Division" means the Workers' Compensation Division of the Department of Labor and Industry.

Subp. 6c. Emergency care. "Emergency care" means those medical services that are required for the immediate diagnosis and treatment of medical conditions that, if not immediately diagnosed and treated, could lead to serious physical or mental disability or death, or that are immediately necessary to alleviate severe pain. Emergency treatment includes treatment delivered in response to symptoms that may or may not represent an actual emergency, but is necessary to determine whether an emergency exists.

Subp. 7. [Repealed, 18 SR 1472]

Subp. 8. [Repealed, 18 SR 1472]

Subp. 9. Injury. "Injury" is as defined in Minnesota Statutes, section 176.011, subdivision 16 as a "personal injury."

Subp. 10. Medical fee schedule. "Medical fee schedule" means the list of codes, service descriptions, and corresponding dollar amounts allowed under Minnesota Statutes, section 176.136, subdivisions 1 and 5, and parts 5221.4000 to 5221.4070.

Subp. 10a. Modifier. "Modifier" means a two-digit number or two-letter symbol that is added to a procedure code to indicate that the service rendered differs in some material respect from the service as described in this chapter or in the CPT or HCPCS manual in effect on the date the service was rendered. Only those modifiers listed and described in the CPT or HCPCS manual in effect on the date the service was rendered may be used. Applicable modifiers must be used with a procedure code, even if the modifier has no effect on the payment level.

Subp. 11. Payer. "Payer" refers to any entity responsible for payment and administration of workers' compensation claims under Minnesota Statutes, chapter 176.

Subp. 11a. Physician. "Physician" means a person who is authorized by law to practice the medical profession within the United States, is in good standing in the profession, and includes only those persons holding the degree D.O. (Doctor of Osteopathy) or M.D. (Doctor of Medicine), as defined in Minnesota Statutes, sections 176.011, subdivision 17, and 176.135, subdivision 2a.

Subp. 12. Provider. "Provider" is as defined in Minnesota Statutes, section 176.011, subdivision 24.

Subp. 13. [Repealed, 18 SR 1472]

Subp. 14. [Repealed, 18 SR 1472]

Subp. 14a. Relative value unit or RVU. "Relative value unit" or "RVU" means the numeric value assigned to a health care service or procedure to represent or quantify its worth, as compared to a standard service.

Subp. 15. Service or treatment. "Service" or "treatment" means any procedure, operation, consultation, supply, product, or other thing performed or provided for the purpose of curing or relieving an injured worker from the effects of a compensable injury under Minnesota Statutes, section 176.135, subdivision 1.

Statutory authority:  MS s 175.171; 176.101; 176.135; 176.1351; 176.136; 176.231; 176.83

History:  9 SR 601; 13 SR 2609; 15 SR 124; 18 SR 1472; 25 SR 1142; L 2002 c 277 s 32; 30 SR 1053

Posted:  June 11, 2008

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