R 418.10106 Procedure codes; relative value units; other billing information.

Rule 106. (1) Upon annual promulgation of R 418.10107, the health care services division of the agency shall provide separate from these rules a manual, tables, and charts containing all of the following information on the agency’s website, www.michigan.gov/leo/bureaus- agencies/wdca: (a) All Current Procedural Terminology (CPT®) procedure codes used for billing healthcare services. (b) Medicine, surgery, and radiology procedures and associated relative value units. (c) Hospital maximum payment ratios. (d) Billing forms and instruction for completion. (2) The procedure codes and standard billing and coding instructions for medicine, surgery, and radiology services are adopted from the most recent publication titled "Current Procedural Terminology (CPT®),” as adopted by reference in R 418.10107. However, billing and coding guidelines published in the CPT codebook do not guarantee reimbursement. A carrier shall only reimburse medical procedures for a work-related injury or illness that are reasonable and necessary and are consistent with accepted medical standards. (3) The formula and methodology for determining the relative value units is adopted from the “RBRVS DataManager Online” as adopted by reference in R 418.10107, using geographical information for this state. The geographical information, (GPCI), is a melded average using 60% of the figures published for the city of Detroit, added to 40% of the figures published for the rest of this state. (4) The maximum allowable payment for medicine, surgery, and radiology services is determined by multiplying the relative value unit assigned to the procedure by the conversion factor listed in the reimbursement section, part 10, of these rules. (5) Procedure codes from "HCPCS 2025 Level II Professional Edition," as adopted by reference in R 418.10107, must be used to describe all the following services: (a) Ambulance services. (b) Medical and surgical expendable supplies. (c) Dental procedures. (d) Durable medical equipment. (e) Vision and hearing services. (f) Home health services. (6) Medical services are considered by report if a procedure code listed in “HCPCS 2025 Level II Professional Edition” or “Current Procedural Terminology (CPT®) 2025 Professional Edition,” as adopted by reference in R 418.10107, does not have an assigned value.