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

5221.0100 Definitions

• Subpart 1. Scope

• Subp. 2. Bill or billing

• Subp. 3. Charge

• Subp. 4. Code

• Subp. 5. Commissioner

• Subp. 6. Compensable injury

• Subp. 9. Injury

• Subp. 10. Medical fee schedule

• Subp. 11. Payer

• Subp. 12. Provider

• Subp. 14a. Relative value unit or RVU

• Subp. 15 Service or treatment

5221.0200 Authority

5221.0300 Purpose

5221.0400 Scope

5221.0405 Incorporations by reference

5221.0410 Required reporting and filing of medical information

• Subpart 1. Scope

• Subp. 2. Health care provider report

• Subp. 3. Maximum medical improvement

• Subp. 4. Permanent partial disability

• Subp. 5. Required reporting to division

• Subp. 6. Report of work ability

• Subp. 7. Payment and coding for required and supplementary reporting

• Subp. 8. Proper filing of documents with division

5221.0420 Health care provider participation with return to work planning

• Subpart 1. Cooperation with return to work planning

• Subp. 2. Communication with assigned qualified rehabilitation consultant

• Subp. 3. Reimbursement for services

5221.0430 Change of health care provider

• Subpart 1. Primary health care provider

• Subp. 2. Change of health care provider

• Subp. 3. Unauthorized change; prohibited payments

• Subp. 4. Change of primary provider not approved

5221.0500 Excessive charges; limitation of payer liability

• Subpart 1. Excessive health care provider charges

• Subp. 2. Limitation of payer liability

• Subp. 3. Collection of excessive charges

5221.0600 Payer responsibilities

• Subpart 1. Compensability

• Subp. 2. Determination of excessiveness

• Subp. 3. Determination of charges

• Subp. 4. Notification

• Subp. 5. Penalties

• Subp. 6. Collection of excessive payment

5221.0650 Data collection, retention and reporting requirements

• Subpart 1. Scope

• Subp. 2. Purpose

• Subp. 3. Retention period

• Subp. 4. Required data

• Subp. 5. Reporting requirements

5221.0700 Provider responsibilities

• Subpart 1. Usual charges

• Subp. 2. Submission of information

• Subp. 3. Billing code

• Subp. 4. Cooperation with payer

5221.4005 Instructions for application of fee schedule

• Subpart 1. Workers' compensation medical fee schedule; incorporation of Medicare National Physician Relative Value Files

• Subp. 2. Effective date

• Subp. 3. Applicability

5221.4010 Employer's liability for services under medical fee schedule

5221.4020 Determining fee schedule payment limits

• Subpart 1b. Conversion factors and maximum fee formulas

• Subp. 1c. Sample calculations

• Subp. 2a. Key to abbreviations and terms and payment instructions

• Subp. 3. Supplies, separate billing allowed

• Subp. 4. Codes 99455 and 99456

5221.4030 -- Medical/surgical procedure codes

• Subpart 1. Key to abbreviations and terms

• Subp. 3. List of medical/surgical procedure codes

5221.4033 Outpatient limitation for medical/surgical facility fee

• Subpart 1. No facility fee

• Subp. 2b. Procedure codes subject to limitation

5221.4035 Fee adjustments for medical/surgical services

• Subpart 1. Definition of a global surgical package

• Subp. 2. Components of a global surgical package

• Subp. 3. Services not included in global surgical package

• Subp. 4. Physicians furnishing less than full global package

• Subp. 5. Coding and payment for multiple surgeries and procedures

• Subp. 6. Coding and payment for bilateral surgeries and procedures

• Subp. 7. Coding and payment for assistant-at-surgery

• Subp. 8. Coding and payment for cosurgeons

• Subp. 9. Coding and payment for team surgery

• Subp. 10. Unbundling surgical services

5221.4040 Pathology and laboratory procedure codes

• Subpart 1. Key to abbreviations and terms

• Subp. 3. List of pathology and laboratory codes

5221.4050 Physical medicine and rehabilitation procedure codes

• Subpart 1. Key to abbreviations and terms

• Subp. 2d. List of physical medicine and rehabilitation codes

• Subp. 3. Additional payment instructions

5221.4051 Fee adjustments for physical medicine and rehabilitation services

5221.4060 Chiropractic procedure codes

• Subpart 1. Key to abbreviations and terms

• Subp. 2d. List of chiropractic procedure codes

• Subp. 3. Select chiropractic procedure code descriptions, instructions and examples

• Subp. 4. Evaluation and management services coding and reporting

5221.4061 Fee adjustments for chiropractic services

• Subpart 1. Multiple modalities

• Subp. 2. Extraspinal code

5221.4070 Pharmacy

• Subpart 1. Substitution of generically equivalent drugs

• Subp. 2. Procedure code; usual and customary charges

• Subp. 3. Maximum fee

• Subp. 4. Maximum fee for electronic transactions

• Subp. 5. Other contracts

5221.6010 -- Authority

5221.6020 Purpose and application

• Subpart 1. Purpose

• Subp. 2. Application

5221.6030 Incorporation by reference

5221.6040 Definitions

• Subpart 1. Scope

• Subp. 2. Active treatment

• Subp. 3. Chronic pain syndrome

• Subp. 4. Condition

• Subp. 5. Emergency treatment

• Subp. 6. Etiology

• Subp. 7. Functional status

• Subp. 8. Initial nonsurgical management or treatment

• Subp. 9. Medical imaging procedures

• Subp. 10. Medically necessary treatment

• Subp. 11. Neurologic deficit

• Subp. 12. Passive treatment

• Subp. 13. Therapeutic injection

5221.6050 General treatment parameters; excessive treatment; prior notification

• Subpart 1. General

• Subp. 2. Documentation

• Subp. 3. Nonoperative treatment

• Subp. 4. Chemical dependency

• Subp. 5. Referrals between health care providers

• Subp. 6. Communication between health care providers and consideration of prior care

• Subp. 7. Determination of excessive treatment; notice of denial to health care providers and employee; expedited processing of medical requests

• Subp. 8. Departures from parameters

• Subp. 9. Prior notification; health care provider and insurer responsibilities

• Subp. 10. Certified managed care plans

• Subp. 11. Outcome studies

5221.6100 Parameters for medical imaging

• Subpart 1. General principles

• Subp. 2. Specific imaging procedures for low back pain

5221.6105 Medications

• Subpart 1. Scope

• Subp. 2. Nonsteroidal anti-inflammatory drugs (NSAIDs)

• Subp. 3. Opiod analgesics

• Subp. 4. Muscle relaxants

5221.6200 Low back pain

• Subpart 1. Diagnostic procedures for treatment of low back injury

• Subp. 2. General treatment parameters for low back pain

• Subp. 3. Passive treatment modalities

• Subp. 4. Active treatment modalities

• Subp. 5. Therapeutic injections

• Subp. 6. Surgery, including decompression procedures and arthrodesis

• Subp. 7. Chronic management

• Subp. 8. Durable medical equipment

• Subp. 9. Evaluation of treatment by health care provider

• Subp. 10. Scheduled and nonscheduled medication

• Subp. 11. Specific treatment parameters for regional low back pain

• Supb. 12. Specific treatment parameters for radicular pain, with or without regional low back pain, with no or static neurologic deficits

• Subp. 13. Specific treatment parameters for cauda equina syndrome and for radicular pain, with or without regional low back pain, with progressive neurologic deficits

5221.6205 Neck pain

• Subpart 1. Diagnostic procedures for treatment of neck injury

• Subp. 2. General treatment parameters for neck pain

• Subp. 3. Passive treatment modalities

• Subp. 4. Active treatment modalities

• Subp. 5. Therapeutic injections

• Subp. 6. Surgery, including decompression procedures and arthrodesis

• Subp. 7. Chronic management

• Subp. 8. Durable medical equipment

• Subp. 9. Evaluation of treatment by health care provider

• Subp. 10. Scheduled and nonscheduled medication

• Subp. 11. Specific treatment parameters for regional neck pain

• Subp. 12. Specific treatment parameters for radicular pain, with or without regional neck pain, with no or static neurologic deficits

• Subp. 13. Specific treatment parameters for radicular pain, with or without regional neck pain, with progressive neurologic changes

• Subp. 14. Specific treatment parameters for myelopathy

5221.6210 Thoracic back pain

• Subpart 1. Diagnostic procedures for treatment of thoracic back injury

• Subp. 2. General treatment parameters for thoracic back pain

• Subp. 3. Passive treatment modalities

• Subp. 4. Active treatment modalities

• Subp. 5. Therapeutic injections

• Subp. 6. Surgery, including decompression procedures

• Subp. 7. Chronic management

• Subp. 8. Durable medical equipment

• Subp. 9. Evaluation of treatment by health care provider

• Subp. 10. Scheduled and nonscheduled medication

• Subp. 11. Specific treatment parameters for regional thoracic back pain

• Subp. 12. Specific treatment parameters for radicular pain

• Subp. 13. Specific treatment parameters for myelopathy

5221.6300 Upper extremity disorders

• Subpart 1. Diagnostic procedures for treatment of upper extremity disorders (UED)

• Subp. 2. General treatment parameters for upper extremity disorders

• Subp. 3. Passive treatment modalities

• Subp. 4. Active treatment modalities

• Subp. 5. Therapeutic injections

• Subp. 6. Surgery

• Subp. 7. Chronic management

• Subp. 8. Durable medical equipment

• Subp. 9. Evaluation of treatment by health care provider

• Subp. 10. Scheduled and nonscheduled medication

• Subp. 11. Specific treatment parameters for epicondylitis

• Subp. 12. Specific treatment parameters for tendonitis of forearm, wrist and hand

• Subp. 13. Specific treatment parameters for nerve entrapment syndromes

• Subp. 14. Specific treatment parameters for muscle pain syndromes

• Subp. 15. Specific treatment parameters for shoulder impingement syndrome

• Subp. 16. Specific treatment parameters for traumatic sprains and strains of the upper extremith

5221.6305 Complex regional pain syndrome (CRPS); reflex sympathetic dystrophy; and causalgia of the upper and lower extremities

• Subpart 1. Scope

• Subp. 2. Initial nonsurgical management

• Subp. 3. Surgery

• Subp. 4. Chronic management

5221.6400 Inpatient hospitalization parameters

• Subpart 1. General principles

• Subp. 2. Specific requirements for hospital admission of patients with low back pain

5221.6500 Parameters for surgical procedures

• Subpart 1. General

• Subp. 2. Spinal injury

• Subp. 3. Upper extremity surgery

• Subp. 4. Lower extremity surgery

5221.6600 Chronic management

• Subpart 1. Scope

• Subp. 2. Chronic management modalities

5221.8900 Disciplinary action; penalties

• Subpart 1. Discipline

• Subp. 2. Complaints

• Subp. 3. Review and investigation

• Subp. 4. Cooperation with disciplinary proceedings

• Subp. 5. In-person meeting

• Subp. 6. Resolution by instruction or written agreement

• Subp. 7. Inappropriate, unnecessary or excessive treatment

• Subp. 8. Violations of statutes and rules other than those involving inappropriate, unnecessary or excessive treatment

• Subp. 9. Penalties