Florida Regulations 69L-7.602pt1

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§ 69L-7.602pt1 Florida Workers' Compensation Medical Services Billing, Filing and Reporting Rule (Part 1).

Editor's note: due to its length, this section has been divided into two sections. For the second half of the section, see 69L-7.602pt2.

(1) Definitions. As used in this rule:

(a) "Accurately Complete" or "Accurately Completed" means the form submitted contains the information necessary to meet the requirements of Chapter 440, F.S., and this rule.

(b) "Adjust" or "Adjusted" means payment is made with modification to the information provided on the bill.

(c) "Agency" means the Agency for Health Care Administration as defined in Section 440.02(3), F.S.

(d) "Ambulatory Surgical Center" is defined in Section 395.002(3), F.S.

(e) "Billing" means the process by which a health care provider submits a medical claim form or medical bill to an insurer, service company/third party administrator or any entity acting on behalf of the insurer, to receive reimbursement for medical services, goods or supplies provided to an injured employee.

(f) "Catastrophic Event" means the occurrence of an event outside the control of an insurer, submitter, service company/third party administrator or any entity acting on behalf of the insurer, such as an electronic data transmission failure due to a natural disaster or an act of terrorism (including but not limited to cyber terrorism), in which recovery time will prevent an insurer, submitter, service company/third party administrator or any entity acting on behalf of the insurer from meeting the filing and reporting requirements of Chapter 440, F.S., and this rule. Programming errors, system malfunctions or electronic data interchange transmission failures that are not a direct result of a catastrophic event are not considered to be a catastrophic event as defined in this rule. See subsection (6)(d) for requirements to request approval of an alternative method and timeline for medical report filing with the Division due to a catastrophic event.

(g) "Charges" means the dollar amount billed.

(h) "Charge Master" means for hospitals a comprehensive listing of all the goods and services for which the facility maintains a separate charge, with the facility's charge for each of the goods and services, regardless of payer type and means for ASCs a listing of the gross charge for each CPT procedure for which an ASC maintains a separate charge, with the ASC's charge for each CPT procedure, regardless of payer type.

(i) "Claims-Handling Entity File Number" means the number assigned to the claim file by the insurer or service company/third party administrator for purposes of internal tracking.

(j) "Current Dental Terminology" (CDT) means the American Dental Association's reference document containing descriptive terms to identify codes for billing and reporting dental procedures.

(k) "Current Procedural Terminology" (CPT) means the American Medical Association's reference document (HCPCS Level I) containing descriptive terms to identify codes for billing and reporting medical procedures and services.

(l) "Date Insurer Paid" or "Date Insurer Paid, Adjusted, Disallowed or Denied" means the date the insurer, service company/third party administrator or any entity acting on behalf of the insurer mails, transfers or electronically transmits payment to the health care provider or the health care provider representative. If payment is disallowed or denied, "Date Insurer Paid" or "Date Insurer Paid, Adjusted, Disallowed or Denied" means the date the insurer, service company/third party administrator or any entity acting on behalf of the insurer mails, transfers or electronically transmits the appropriate notice of disallowance or denial to the health care provider or the health care provider representative. See paragraph (5)(1) for the requirement to accurately report the "date insurer paid".

(m) "Date Insurer Received" means the date that a Form DFS-F5-DWC-9, DFS-F5-DWC-10 (or insurer pre-approved alternate form), DFS-F5-DWC-11, DFS-F5-DWC-90 or the electronic form equivalent is in the possession of the insurer, service company/third party administrator or any entity acting on behalf of the insurer. See subparagraph (5)(l) for the requirement to accurately report the "date insurer received". If a medical bill meets any of the critiera in (5)(j) of this rule and possession of the form is relinquished by the insurer, service company/TPA or any entity acting on behalf of the insurer by returning the medical bill to the provider with a written explanation for the insurer's reason for return, then "date insurer received" shall not apply to the medical bill as submitted.

(n) "Deny" or "Denied" means payment is not made because the service rendered is treatment for a non-compensable injury or illness.

(o) "Department" means Department of Financial Services (DFS) as defined in Section 440.02(12), F.S.

(p) "Disallow" or "Disallowed" means payment is not made because the service rendered has not been substantiated for reasons of medical necessity, insufficient documentation, lack of authorization or billing error.

(q) "Division" means the Division of Workers' Compensation (DWC) as defined in Section 440.02(14), F.S.

(r) "Electronic Filing" means the computer exchange of medical data from a submitter to the Division in the standardized format defined in the Florida Medical EDI Implementation Guide (MEIG).

(s) "Electronic Form Equivalent" means the format, provided in the Florida Medical EDI Implementation Guide (MEIG) to be used when a submitter electronically transmits required data to the Division. Electronic form equivalents do not include transmission by facsimile, data file(s) attached to electronic mail, or computer-generated paper-forms.

(t) "Electronically Filed with the Division" means the date an electronic filing has been received by the Division and has successfully passed structural and data-quality edits.

(u) "Entity" means any party involved in the provision of or the payment for medical services, care or treatment rendered to the injured employee, excluding the insurer, service company/third party administrator or health care provider as identified in this section.

(v) "Explanation of Bill Review" (EOBR) means the notice of payment or notice of adjustment, disallowance or denial sent by an insurer, service company/third party administrator or any entity acting on behalf of an insurer to a health care provider containing code(s) and code descriptor(s), in conformance with paragraph (5)(o) of this rule.

(w) "Florida Medical EDI Implementation Guide (MEIG)" is the Florida Division of Workers' Compensation's reference document containing the specific electronic formats and data elements required for insurer reporting of medical data to the Division.

(x) "Healthcare Common Procedure Coding System National Level II Codes (HCPCS)" (HCPCS) means the Centers for Medicare and Medicaid Services' (CMS) reference document listing descriptive codes for billing and reporting professional services, procedures, and supplies provided by health care providers.

(y) "Health Care Provider" is defined in Section 440.13(1)(h), F.S.

(z) "Hospital" is defined in Section 395.002(13), F.S.

(aa) "ICD-9-CM International Classification of Diseases" (ICD-9) is the U.S. Department of Health and Human Services' reference document listing the official diagnosis and inpatient-procedure code sets.

(bb) "Insurer" is defined in Section 440.02(38), F.S.

(cc) "Insurer Code Number" means the number the Division assigns to each individual insurer, self-insured employer or self-insured fund.

(dd) "Itemized Statement" means a detailed listing of goods, services and supplies provided to an injured employee, including the quantity and charges for each good, service or supply.

(ee) "Medical Bill" means the document or electronic equivalent submitted by a health care provider to an insurer, service company/TPA or any entity acting on behalf of the insurer for reimbursement for services or supplies (e.g. DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11, DFS-F5-DWC-90 or the provider's usual invoice or business letterhead) as appropriate pursuant to subsection (4)(b) of this rule.

(ff) "Medically Necessary" or "Medical Necessity" is defined in Section 440.13(1)(l), F.S.

(gg) "NDC Number" means the National Drug Code (NDC) number, assigned under Section 510 of the Federal Food, Drug, and Cosmetic Act, which identifies the drug product labeler/vendor, product, and trade package size. The NDC number is an eleven-digit number that is expressed in the universal 5-4-2 format and included on all applicable reports with each of the three segments separated by a dash (-).

(hh) "Pay" or "Paid" means payment is made applying the applicable reimbursement formula to the medical bill as submitted.

(ii) "Physician" is defined in Section 440.13(1)(q), F.S.

(jj) "Principal Physician" means the treating physician responsible for the oversight of medical care, treatment and attendance rendered to an injured employee, to include recommendation for appropriate consultations or referrals.

(kk) "Report" means any form related to medical services rendered, in relation to a workers' compensation injury, that is required to be filed with the Division under this rule.

(ll) "Service Company/Third Party Administrator (TPA)" means a party that has contracted with an insurer for the purpose of providing services necessary to adjust workers' compensation claims on the insurer's behalf.

(mm) "Service Company/Third Party Administrator (TPA) Code Number" means the number the Division assigns to a service company, adjusting company, managing general agent or third party administrator.

(nn) "Submitter" means an insurer, service company/TPA, entity or any other party acting as an agent on behalf of an insurer, service company/TPA or any entity to fulfill any insurer responsibility to electronically transmit required medical data to the Division.

(oo) "UB-92, National Uniform Billing Data Element Specifications as Adopted by the Florida State Uniform Billing Committee, November 2006" (UB-92 Manual) is the reference document providing billing and reporting completion instructions for the Form DFS-F5-DWC-90 (UB-92 HCFA-1450, Uniform Bill, Rev. 1992).

(pp) "UB 04 Manual" means the National Uniform Billing Committee Official UB-04 Data Specifications Manual 2007, which is the reference document providing billing and reporting completion instructions for the Form DFS-F5-DWC-90 (UB-04 CMS-1450, Uniform Bill, Rev. 2007).

(2) Forms Incorporated by Reference for Medical Billing, Filing and Reporting.

(a)1. Form DFS-F5-DWC-9 (CMS-1500 Health Insurance Claim Form, Rev. 12/90); Form DFS-F5-DWC-9-A (Completion Instructions for Form DFS-F5-DWC-9: comprised of three sets of completion instructions for use by health care providers, ambulatory surgical centers, and work hardening and pain management programs), Rev. 5/26/05. Effective to bill for dates of service up to and including 03/31/07.

2. Form DFS-F5-DWC-9 (CMS-1500 Health Insurance Claim Form, Rev. 08/05); Form DFS-F5-DWC-9-B (Completion Instructions for Form DFS-F5-DWC-9: comprised of three sets of completion instructions for use by health care providers, ambulatory surgical centers, and work hardening and pain management programs), Rev. 1/1/07. May be used to bill for dates of service up to and including 3/31/07 and shall be used to bill for dates of service on and after 4/1/07.

(b)1. Form DFS-F5-DWC-10 (Statement of Charges for Drugs and Medical Supplies Form), Rev. 2/14/06. Effective to bill for dates of service up to and including 3/31/07.

2. Form DFS-F5-DWC-10 (Statement of Charges for Drugs and Medical Supplies Form), Rev. 1/1/07. May be used to bill for dates of service up to and including 3/31/07 and shall be used to bill for dates of service on and after 4/1/07.

(c)1. Form DFS-F5-DWC-11 (American Dental Association Dental Claim Form, Rev. 2002); Form DFS-F5-DWC-11-A (Completion Instructions for Form DFS-F5-DWC-11), Rev. 5/26/05. Effective to bill for dates of service up to and including 3/31/07.

2. Form DFS-F5-DWC-11 (American Dental Association Dental Claim Form, Rev. 2006); Form DFS-F5-DWC-11-B (Completion Instructions for Form DFS-F5-DWC-11), Rev. 1/1/07. May be used to bill for dates of service up to and including 3/31/07 and shall be used to bill for dates of service on and after 4/1/07.

(d) Form DFS-F5-DWC-25 (Florida Workers' Compensation Uniform Medical Treatment/Status Reporting Form), Rev. 2/14/06.

(e)1. Form DFS-F5-DWC-90 (UB-92 HCFA-1450, Uniform Bill, Rev. 1992). Effective for submissions up to and including 5/22/07.

2. Form DFS-F5-DWC-90 (UB-04 CMS-1450, Uniform Bill, Rev. 2006); Form DFS-F5-DWC-90-B (Completion Instructions for Form DFS-F5-DWC-90), Rev. 1/1/07. May be used to bill for submissions between 3/1/07 and 5/22/07 and shall be used to bill for submissions on and after 5/23/07.

(f) Obtaining Copies of Forms and Instructions. 1. A copy of either revision of the Form DFS-F5-DWC-9 can be obtained from the CMS web site: http://www.cms.hhs.gov/forms/#7. Completion instructions for either revision of the form can be obtained from the Department of Financial Services/Division of Workers' Compensation (DFS/DWC) web site: http://www.fldfs.com/WC/forms.html#7.

2. A copy of either revision of the Form DFS-F5-DWC-10 and completion instructions for either revision of the form can be obtained from the DFS/DWC web site: http://www.fldfs.com/WC/forms.html#7.

3. A copy of either revision of the Form DFS-F5-DWC-11 can be obtained from the American Dental Association web site: http://www.ada.org/. Completion instructions for either revision of the form can be obtained from the DFS/DWC web site: http://www.fldfs.com/WC/forms.html#7.

4. A copy of the Form DFS-F5-DWC-25 and completion instructions can be obtained from the DFS/DWC web site: http://www.fldfs.com/WC/forms.html#7.

5. A copy of either revision of the Form DFS-F5-DWC-90 can be obtained from the CMS web site: http://www.cms.hhs.gov/forms/. Completion instructions for Form DFS-F5-DWC-90 (Rev. 1992) can be obtained from the UB-92, National Uniform Billing Data Element Specifications as Adopted by the Florida State Uniform Billing Committee (Rev. September 2006) and subparagraph (4)(b)4. of this rule. Completion instructions for Form DFS-F5-DWC-90 (Rev. 2006), Form DFS-F5-DWC-90-B (Rev. 1/1/07), can be obtained from the DFS/DWC web site: http://www.fldfs.com/WC/forms.html#7.

(g) In lieu of submitting a Form DFS-F5-DWC-10, when billing for drugs or medical supplies, alternate billing forms are acceptable if:

1. An insurer has approved the alternate billing form(s) prior to submission by a health care provider, and

2. The form provides all information required to be submitted to the Division, pursuant to the date-applicable Florida Medical EDI Implementation Guide (MEIG), on the Form DFS-F5-DWC-10. Form DFS-F5-DWC-9, DFS-F5-DWC-11 or DFS-F5-DWC-90 shall not be submitted as an alternate form.

(3) Materials Adopted by Reference. The following publications are incorporated by reference herein:

(a) UB-92, National Uniform Billing Data Element Specifications as Adopted by the Florida State Uniform Billing Committee (Rev. September 2006). A copy of this manual can be obtained from the Florida Hospital Association by calling (407) 841-6230.

(b) The Florida Medical EDI Implementation Guide (MEIG), 2006, applicable for data submission until 7/1/07. The Florida Medical EDI Implementation Guide (MEIG), 2006 can be obtained from the DFS/DWC web site: http://www.fldfs.com/WC/edi_med.html.

(c) The American Medical Association Healthcare Common Procedure Coding System, Medicare's National Level II Codes (HCPCS), as adopted in Rule 69L-7.020, F.A.C.

(d) The Current Procedural Terminology (CPT), as adopted in Rule 69L-7.020, F.A.C.

(e) The Current Dental Terminology (CDT-2005), as adopted in Rule 69L-7.020, F.A.C.

(f) The 2007 ICD-9-CM Professional for Hospitals, Volumes 1, 2 and 3, International Classification of Diseases, 9th Revision, Clinical Modification, Copyright 2006, Ingenix, Inc. (American Medical Association).

(g) The Physician ICD-9-CM 2007, Volumes 1 & 2, International Classification of Diseases, 9th Revision, Clinical Modification, Copyright 2006, Ingenix, Inc. (American Medical Association).

(h) The American Medical Association's Guide to the Evaluation of Permanent Impairment, as adopted in Rule 69L-7.604, F.A.C.

(i) The Minnesota Department of Labor and Industry Disability Schedule, as adopted in Rule 69L-7.604, F.A.C.

(j) The Florida Impairment Rating Guide, as adopted in Rule 69L-7.604, F.A.C.

(k) The 1996 Florida Uniform Permanent Impairment Rating Schedule, as adopted in Rule 69L-7.604, F.A.C.

(l) National Uniform Billing Committee Official UB-04 Data Specifications Manual 2007, version 1.00, September 2006, as adopted by the National Uniform Billing Committee. A copy of this manual can be obtained from the National Uniform Billing Committee web site: http://www.nubc.org/UB-04%20SUBSCRIPTION%20ORDER%20FORM.doc

(m) The Florida Medical EDI Implementation Guide (MEIG), 2007, applicable for data submission on or after 4/2/07 and required for all data submission on or after 8/9/07. The Florida Medical EDI Implementation Guide (MEIG), 2007 can be obtained from the DFS/DWC web site: http://www.fldfs.com/WC/edi_med.html.

(n) Current Procedural Terminology (CPT), 2007 Professional Edition, Copyright 2006, American Medical Association.

(4) Health Care Provider Responsibilities.

(a) Bill Submission/Filing and Reporting Requirements.

1. All health care providers are responsible for meeting their obligations, under this rule, regardless of any business arrangement with any entity under which claims are prepared, processed or submitted to the insurer.

2. Each health care provider is responsible for submitting any additional form completion information and supporting documentation requested, in writing, by the insurer at the time of authorization or at the time a reimbursement request is received.

3. Each health care provider shall resubmit a medical claim form or medical bill with insurer requested documentation when the EOBR provides an explanation for disallowance based on the lack of documentation submitted with the medical bill.

4. Insurers and health care providers shall utilize only the Form DFS-F5-DWC-25 for physician reporting of the injured employee's medical treatment/status. Any other reporting forms may not be used in lieu of or supplemental to the Form DFS-F5-DWC-25. Provider failure to accurately complete and submit the DFS-F5-DWC-25, in accordance with the Form DFS-F5-DWC-25 Completion/Submission Instructions adopted in this rule, may result in the Agency imposing sanctions or penalties pursuant to subsection 440.13(8), F.S. or subsection 440.13(11), F.S.

a. The Form DFS-F5-DWC-25 does not replace physician notes, medical records or Division-required medical reports.

b. All information submitted on physician notes, medical records or Division-required medical reports must be consistent with information documented on the Form DFS-F5-DWC-25.

5. All medical claim form(s) or medical bill(s) related to services rendered for a compensable injury shall be submitted by a health care provider to the insurer, service company/TPA or any entity acting on behalf of the insurer, as a requirement for billing.

6. Medical claim form(s) or medical bill(s) may be electronically filed or submitted via facsimile by a health care provider to the insurer, service company/TPA or any entity on behalf of the insurer, provided the insurer agrees.

7. When requested by the insurer, service company/TPA or any entity acting on behalf of the insurer, a health care provider shall send documentation that supports the medical necessity of the specific services rendered and any other required documentation pursuant to paragraph (4)(b) of this rule and the applicable reimbursement manual.

8. Each health care provider is responsible for correcting and resubmitting any billing forms returned by an insurer, service company/TPA or any entity acting on behalf of the insurer pursuant to paragraph (5)(j) of this rule.

9. Each hospital and ambulatory surgical center shall maintain its charge master and shall produce relevant portions when requested for the purpose of verifying its usual charges pursuant to Section 440.13(12)(d), F.S.

(b) Special Billing Requirements.

1. When anesthesia services are billed on a Form DFS-F5-DWC-9, completion of the form must include the CPT code and the "P" code (physical status modifier), which correspond with the procedure performed, in Field 24D. Anesthesia health care providers shall enter the date of service and the 5-digit qualifying circumstance code, which correspond with the procedure performed, in Field 24D on the next line, if applicable.

2. When an Advanced Registered Nurse Practitioner (ARNP) provides services as a Certified Registered Nurse Anesthetist, the ARNP shall bill on a Form DFS-F5-DWC-9 for the services rendered and enter his/her Florida Department of Health ARNP license number in Field 33b, regardless of the employment arrangement under which the services were rendered, or the party submitting the bill.

3. Regardless of the employment arrangement under which the services are rendered or the party submitting the bill, the following health care providers, who render direct billable services for which reimbursement is sought from an insurer, service company/TPA or any entity acting on behalf of the insurer, service company/TPA, shall bill on a Form DFS-F5-DWC-9 and enter his/her Florida Department of Health license number in Field 33b on the Form DFS-F5-DWC-9:

a. Any licensed physician; or

b. Any non-physician health care provider, including a physician assistant or an ARNP (not providing an anesthesia-related service); or

c. Any licensed non-physician health care provider who is seeking reimbursement under his or her license number issued by the Florida Department of Health.

4. For hospital billing, the following special requirements apply:

a. Inpatient billing - Hospitals shall, in addition to filing a Form DFS-F5-DWC-90:

I. Attach an itemized statement with charges based on the facility's Charge Master; and

II. Submit all applicable documentation or certification required pursuant to Rule 69L-7.501, F.A.C.; and

III. Bill professional services provided by a physician, physician assistant, advanced registered nurse practitioner, or registered nurse first assistant on the Form DFS-F5-DWC-9, regardless of employment arrangement.

IV. When entering the CPT, HCPCS or unique workers' compensation codes in Form Locator 44 on the Form DFS-F5-DWC-90, the hospital shall utilize CPT, HCPCS or unique workers' compensation codes provided in the Florida Workers' Compensation Health Care Provider Reimbursement Manual adopted in Rule 69L-7.501, F.A.C.

b. Outpatient billing - Hospitals shall in addition to filing a Form DFS-F5-DWC-90:

I. Enter the CPT, HCPCS or unique workers' compensation code (provided in the Florida Workers' Compensation Health Care Provider Reimbursement Manual as incorporated for reference in Rule 69L-7.501, F.A.C.) in Form Locator 44 on the Form DFS-F5-DWC-90, to bill outpatient radiology, clinical laboratory and physical, occupational or speech therapy charges; and

II. Make written entry "scheduled" or "non-scheduled" in Form Locator 84 of Form revision 1992 and in Form Locator 80 of Form revision 2006 - �Remarks' on the DFS-F5-DWC-90, when billing outpatient surgery or outpatient surgical services; and

III. Make written entry "implant(s)" followed by the reimbursement calculation made pursuant to Rule 69L-7.501, F.A.C., in Form Locator 84 of Form revision 1992 and in Form Locator 80 of Form revision 2006 - �Remarks' on the DFS-F5-DWC-90, directly after entry of "scheduled" or "non-scheduled", when present.

IV. Attach an itemized statement with charges based on the facility's Charge Master if there is no line item detail shown on the Form DFS-F5-DWC-90; and

V. Submit all applicable documentation or certification required pursuant to Rule 69L-7.501, F.A.C.

VI. Bill professional services provided by a physician, physician assistant, advanced registered nurse practitioner, or registered nurse first assistant on the Form DFS-F5-DWC-9, regardless of employment arrangement,

5. A certified, licensed physician assistant, anesthesia assistant and registered nurse first assistant who provides services as a surgical assistant, in lieu of a second physician, shall bill on a Form DFS-F5-DWC-9 entering the CPT code(s) plus modifier(s), which represent the service(s) rendered, in Field 24D, and must enter his/her Florida Department of Health license number in Field 33b.

6. Ambulatory Surgical Centers (ASCs) shall bill on a Form DFS-F5-DWC-9 using the American Medical Association's CPT procedure codes, or using the unique workers' compensation procedure code 99070 and billing charges based on the ASC's Charge Master except when billing for procedure code 99070. ASC medical bills shall be accompanied by all applicable documentation required pursuant to Rule 69L-7.100, F.A.C.

7. Federal Facilities shall bill on their usual form.

8. Out-of-State health care providers shall bill on the applicable medical bill form pursuant to paragraph (4)(c) of this rule. 9. Dental Services.

a. Dentists shall bill for services on a Form DFS-F5-DWC-11.

b. Oral surgeons shall bill for oral and maxillofacial surgical services on a Form DFS-F5-DWC-9. Non-surgical dental services shall be billed on a Form DFS-F5-DWC-11.

10. Pharmaceutical(s), Durable Medical Equipment and Medical Supplies.

a. When dispensing commercially available medicinal drugs commonly known as legend or prescription drugs:

I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the NDC number, in the universal 5-4-2 format, in Field 9, with each segment separated by a dash (-).

II. Physicians, physician assistants or ARNPs shall bill on Form DFS-F5-DWC-9 and shall enter the NDC number, in the universal 5-4-2 format, in Field 24D, with each segment separated by a dash (-). Optionally, the unique workers' compensation code 96370 may be entered in addition to the NDC number in Field 24D.

III. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.

b. When dispensing medicinal drugs which are compounded and the prescribed formulation is not commercially available:

I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the unique workers' compensation code 96371 in Field 9.

II. Physicians, physician assistants or ARNPs shall bill on Form DFS-F5-DWC-9 and shall enter the unique workers' compensation code 96371 in form Field 24D.

III. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.

c. When dispensing over-the-counter drug products:

I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the NDC number, in the universal 5-4-2 format in form Field 9, with each segment separated by a dash (-).

II. Physicians, physician assistants or ARNPs shall bill on Form DFS-F5-DWC-9, shall enter the NDC number in the universal 5-4-2 format, in Field 24D, with each segment separated by a dash (-). The requirement to enter the NDC number in Field 24D supersedes the instruction to enter 99070 in the Florida Workers' Compensation Health Care Provider Reimbursement Manual.

III. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.

d. When administering or dispensing injectable drugs:

I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the NDC number, in the universal 5-4-2 format, in form Field 9, with each segment separated by a dash (-).

II. Physicians, physician assistants or ARNPs shall bill on a Form DFS-F5-DWC-9 and enter the appropriate HCPCS "J" code in form Field 24D. When an appropriate HCPCS "J" code is not available for the injectable drug, enter the NDC number, in the universal 5-4-2 format in form Field 24D with each segment separated by a dash (-).

III. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.

e. When dispensing durable medical equipment (DME):

I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in Field 21 on form revision 2/14/06 and in Field 21 on form revision 1/1/07.

II. Physicians, physician assistants or ARNPs shall bill on Form DFS-F5-DWC-9, shall enter the applicable HCPCS code in Field 24D and attach documentation indicating the actual cost of the supply, including applicable manufacturer's shipping and handling.

III. Hospitals shall bill on Form DFS-F5-DWC-90 using the applicable revenue codes.

IV. Ambulatory Surgical Centers shall bill for these products on Form DFS-F5-DWC-9 using applicable HCPCS codes.

V. Medical Suppliers shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in form Field 21 on form revision 2/14/06 and in Field 21 on form revision 1/1/07. The requirement to enter the HCPCS code when billing for medical equipment or supplies supersedes the instruction that "the medical supplier is not required to submit codes" in the Florida Workers' Compensation Health Care Provider Reimbursement Manual.

f. When dispensing medical supplies which are not incidental to a service or procedure:

I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in Field 16 on form revision 2/14/06 and in Field 21 on form revision 1/1/07.

II. Physicians, physician assistants or ARNPs shall bill on Form DFS-F5-DWC-9, shall enter the applicable HCPCS code in Field 24D and attach documentation indicating the actual cost of the supply, including applicable manufacturer's shipping and handling. The requirement to enter the HCPCS code when billing for medical equipment or supplies supersedes the instruction "under the specific HCPCS code or 99070" in the Florida Workers' Compensation Health Care Provider Reimbursement Manual.

III. Hospitals shall bill on Form DFS-F5-DWC-90 under the applicable revenue codes.

IV. Ambulatory Surgical Centers shall bill separately for these products on Form DFS-F5-DWC-9 and shall enter the applicable CPT code or HCPCS in Field 24D.

V. Medical Suppliers shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in Field 16 on form revision 2/14/06 and in Field 19 on form revision 1/1/07. The requirement to enter the HCPCS code when billing for medical equipment or supplies supersedes the instruction that "the medical supplier is not required to submit codes" in the Florida Workers' Compensation Health Care Provider Reimbursement Manual.

g. Pharmacists who provide Medication Therapy Management Services shall bill for these services on a Form DFS-F5-DWC-9 by entering the appropriate CPT code(s) 0115T, 0116T or 0117T that represent the service(s) rendered in form Field 24D, shall enter their Florida Department of Health license number in Field 33b and shall submit a copy of the physician's written prescription with the medical bill.

h. Pharmacists and medical suppliers may only bill on an alternate to Form DFS-F5-DWC-10 when an insurer has pre-approved use of the alternate form. Forms DFS-F5-DWC-9, DFS-F5-DWC-11 or DFS-F5-DWC-90 shall not be approved for use as the alternate form.

11. Physicians billing for a failed appointment for a scheduled independent medical examination (when the injured employee does not report to the physician office as scheduled) shall bill on their invoice or letterhead. The invoice shall not be a Form DFS-F5-DWC-9, , DFS-F5-DWC-10, DFS-F5-DWC-11, or DFS-F5-DWC-90.

12. Health care providers receiving reimbursement under any payment plan (pre-payment, prospective pay, capitation, etc.) must accurately complete the Form DFS-F5-DWC-9 and submit the form to the insurer.

13. Health care providers and other insurer-authorized providers rendering services reimbursable under workers' compensation, whose billing requirements are not otherwise specified in this rule (e.g. home health agencies, independent, non-hospital based ambulance services, air- ambulance, emergency medical transportation, non-emergency transportation services, translation services, etc.) shall bill on their invoice or business letterhead. These providers shall not submit the Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11 or DFS-F5-DWC-90 as an invoice.

Editor's note: due to its length, this section has been divided into two sections. For the second half of the section, see 69L-7.602pt2.