R 418.10404 Follow-up care occurring during global service.

Rule 404. (1) Follow-up care for a diagnostic procedure must refer only to the days required to recover from the diagnostic procedure and not the treatment of the underlying condition. (2) Follow-up care for therapeutic surgical procedures includes only that care that is usually part of the surgical service. Complications, exacerbations, recurrence, or the presence of other compensable diseases or injuries requiring additional services must be reported with the identification of appropriate procedures. The follow-up days for the surgical procedures are adopted from the “RBRVS DataManager Online” as referenced in R 418.10107. The follow-up days for each surgical procedure are provided separate from these rules on the agency’s website, https://www.michigan.gov/leo/bureaus-agencies/wdca. All of the following apply to the global service provider: (a) If a carrier requests the surgeon to see an injured worker during the global service period for the purpose of job restrictions, job adjustments, or return to work, the visit is not considered part of the global surgery package. If the carrier requests the visit, the carrier shall prior authorize the visit by assigning an authorization number. The provider shall bill the visit using procedure code 99455 and modifier -32, including the authorization number in box 23 of the CMS 1500 claim form. The carrier shall not deny a prior authorized visit and shall reimburse the provider for the prior authorized visit. The maximum allowable payment for procedure code 99455-32 must be listed in the manual published separate from these rules. (b) The medical record must reflect job adjustments, job restrictions or limitations, or return to work date, and the provider shall include the medical record with the bill. (c) If an insured employer requests the surgeon to see an injured worker during the global surgery period for the purpose of job adjustments, restrictions, or return to work, the employer shall obtain the prior authorization number from the carrier for the visit. (3) Hospital follow-up care or a hospital visit by the practitioner responsible for the surgery is considered part of the surgical follow-up days listed for the procedure and is not paid as an independent procedure.