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§ 134.220. Case Management Services

Case management responsibilities by the treating doctor are as follows:

(1) Team conferences and telephone calls shall include coordination with an interdisciplinary team.

(A) Team members shall not be employees of the treating doctor.

(B) Team conferences and telephone calls must be outside of an interdisciplinary program. Documentation shall include the purpose and outcome of conferences and telephone calls, and the name and specialty of each individual attending the team conference or engaged in a phone call.

(2) Team conferences and telephone calls should be triggered by a documented change in the condition of the injured employee and performed for the purpose of coordination of medical treatment and/or return to work for the injured employee.

(3) Contact with one or more members of the interdisciplinary team more often than once every 30 days shall be limited to the following:

(A) coordinating with the employer, employee, or an assigned medical or vocational case manager to determine return to work options;

(B) developing or revising a treatment plan, including any treatment plans required by division rules;

(C) altering or clarifying previous instructions; or

(D) coordinating the care of employees with catastrophic or multiple injuries requiring multiple specialties.

(4) Case management services require the treating doctor to submit documentation that identifies any health care provider that contributes to the case management activity. Case management services shall be billed and reimbursed as follows:

(A) CPT code 99361.

(i) Reimbursement to the treating doctor shall be $113. Modifier “W1” shall be added.

(ii) Reimbursement to the referral health care provider shall be $28 when a health care provider contributes to the case management activity.

(B) CPT code 99362.

(i) Reimbursement to the treating doctor shall be $198. Modifier “W1” shall be added.

(ii) Reimbursement to the referral health care provider shall be $50 when a health care provider contributes to the case management activity.

(C) CPT code 99371.

(i) Reimbursement to the treating doctor shall be $18. Modifier “W1” shall be added.

(ii) Reimbursement to a referral health care provider contributing to this case management activity shall be $5.

(D) CPT code 99372.

(i) Reimbursement to the treating doctor shall be $46. Modifier “W1” shall be added.

(ii) Reimbursement to the referral health care provider contributing to this case management activity shall be $12.

(E) CPT code 99373.

(i) Reimbursement to the treating doctor shall be $90. Modifier “W1” shall be added.

(ii) Reimbursement to the referral health care provider contributing to this case management action shall be $23.

The provisions of this §134.220 adopted to be July 7, 2016, 41 TexReg 4839.

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At a Glance:

Title:

§ 134.220. Case Management Services

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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