20 Miss. Code R. § 2-IV
Act means Mississippi Workers' Compensation Law, Mississippi Code Annotated (MCA), § 71-3-1 et seq (Rev. 2000 as amended).
Adjust means that a payer or a payer's agent reduces or otherwise alters a health care provider's request for payment.
APC means ambulatory payment classification and guidelines for hospital outpatient and ambulatory surgery center facilities as developed by the Centers for Medicare and Medicaid Services (CMS) and adopted in this Fee Schedule.
Appropriate care means health care that is suitable for a particular patient, condition, occasion, or place.
AWP means Average Wholesale Price; and is based on data obtained from manufacturers.
Bill means a claim submitted by a provider to a payer for payment of health care services provided in connection with a covered injury or illness.
Bill adjustment means a reduction of a fee on a provider's bill, or other alteration of a provider's bill.
By report (BR) means that the procedure is new, or is not assigned a maximum fee, and requires a written description included on or attached to the bill. "By report" (BR) procedures require a complete listing/description of the service, the dates of service, the procedure code, and the payment requested. The report is included in the request for reimbursement for the procedure.
Carrier means any stock company, mutual company, or reciprocal or inter-insurance exchange authorized to write or carry on the business of Workers' Compensation Insurance in this State, or self-insured group, or third-party payer, or self-insured employer, or uninsured employer.
CARF , the Commission on Accreditation of Rehabilitation Facilities, is an independent, nonprofit accreditor of health and human services such as medical rehabilitation facilities.
Case means a covered injury or illness occurring on a specific date and identified by the worker's name and date of injury or illness.
CDT means Current Dental Terminology, a medical code set maintained and copyrighted by the American Dental Association, which is used for reporting dental services.
CMS-1500 means the CMS-1500 form and instructions that are used by non-institutional providers and suppliers to bill for outpatient services. Use of the most current CMS-1500 form is required.
Commission means the Mississippi Workers' Compensation Commission (MWCC).
Consultation means a service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. If a consultant, subsequent to the first encounter, assumes responsibility for management of the patient's condition, that physician becomes a treating physician. The first encounter is a consultation and shall be billed and reimbursed as such. A consultant shall provide a written report of his/her findings. A second opinion is considered a consultation.
Controverted claim is a workers' compensation claim which is pending before the MWCC and in which the patient or patient's legal representative has filed a Petition to Controvert.
Covered injury or illness means an injury or illness for which treatment is mandated under the Act.
Critical care means care rendered in a variety of medical emergencies that requires the constant attention of the practitioner, such as cardiac arrest, shock, bleeding, respiratory failure, postoperative complications, and is usually provided in a critical care unit or an emergency department.
CPT (Current Procedural Terminology) means a set of codes, descriptions, and guidelines developed by the American Medical Association, intended to describe procedures and services performed by physicians and other health care professionals. The CPT code set is also used by other entities to report outpatient services. Each procedure or service is identified with a five-digit code. CPT codes may also be referred to as HCPCS Level I codes.
Day means a continuous 24-hour period.
Diagnostic procedure means a service that helps determine the nature and causes of a disease or injury.
Durable medical equipment (DME) means specialized equipment designed to stand repeated use, appropriate for home use, and used solely for medical purposes.
Employer Medical Evaluation (EME) means a second opinion evaluation available to the Employer or Carrier pursuant to MCA § 71-3-15(1) (Rev. 2000) for the purpose of evaluating temporary or permanent disability, or the medical treatment being rendered to the injured worker.
Expendable medical supply means a disposable article that is needed in quantity on a daily or monthly basis.
Follow-up care means the care which is related to the recovery from a specific procedure and which is considered part of the procedure's maximum allowable reimbursement, but does not include complications.
Follow-up days (FUD) are the days of care following a surgical procedure which are included in the procedure's maximum allowable reimbursement amount, but which do not include follow up care related to complications. The follow-up day period begins on the day of the surgical procedure(s).
HCPCS means Healthcare Common Procedure Coding System, an alpha-numeric medical code set maintained by the Centers for Medicare and Medicaid Services used for reporting services, durable medical equipment, and supplies. CPT codes are Level I HCPCS codes. HCPCS codes may also be referred to as HCPCS Level II codes.
Health care review means the review of a health care case, bill, or both by the payer or the payer's agent.
Incident - to means that services and supplies are commonly furnished as an integral part of the primary service or procedure and not reimbursed separately.
Incidental surgery means surgery performed through the same incision, on the same day, by the same doctor, not increasing the difficulty or follow-up of the main procedure, or not related to the diagnosis.
Independent medical examination (IME) means a consultation provided by a physician to evaluate a patient at the request of the MWCC. This evaluation may include an extensive record review and physical examination of the patient and requires a written report.
Independent procedure means a procedure that may be carried out by itself, completely separate and apart from the total service that usually accompanies it.
Inpatient services means services rendered to a person who is admitted to a hospital as an inpatient.
MAR (See Maximum allowable reimbursement)
Maximum allowable reimbursement (MAR) means the maximum amount allowed for medical services as set forth in this Fee Schedule.
Medical only case means a case that does not involve more than five (5) days of disability or lost work time and for which only medical treatment is required.
Medically accepted standard means a measure set by a competent authority as the rule for evaluating quality or quantity of health care or health care services and which may be defined in relation to any of the following:
* Professional performance;
* Professional credentials;
* The actual or predicted effects of care; and
* The range of variation from the norm.
MWCC means the Mississippi Workers' Compensation Commission.
Medically necessary means any reasonable medical service or supply used to identify or treat a work-related injury/illness which is appropriate to the patient's diagnosis, is based upon accepted standards of the health care specialty involved, represents an appropriate level of care given the location of service, the nature and seriousness of the condition, and the frequency and duration of services, is not experimental or investigational, and is consistent with or comparable to the treatment of like or similar non-work related injuries. Utilization management or review decisions shall not be based on application of clinical guidelines, but must include review of clinical information submitted by the provider and represent an individualized determination based on the worker's current condition and the concept of medical necessity predicated on objective or appropriate subjective improvements in the patient's clinical status.
Medical record means a record in which the medical service provider records the subjective findings, objective findings, diagnosis, treatment rendered, treatment plan, and return to work status and/or goals and impairment rating as applicable.
Medical supply means either a piece of durable medical equipment or an expendable medical supply.
National Correct Coding Initiative (NCCI) means an initiative implemented by the Centers for Medicare and Medicaid Services' (CMS) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. NCCI Procedure-to-Procedure (PTP) code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together. Medically Unlikely Edits (MUEs) are the maximum number of Units of Service (UOS) allowable under most circumstances for a single Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code billed by a provider on a date of service.
NCCI (See National Correct Coding Initiative.)
Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital..
Operative report means the practitioner's written description of the surgery or procedure and includes all of the following:
* A preoperative diagnosis;
* A postoperative diagnosis;
* A step-by-step description of the surgery;
* A description of any problems that occurred in surgery; and
* The condition of the patient upon leaving the operating room.
Optometrist means an individual licensed to practice optometry.
Orthotic equipment means an orthopedic apparatus designed to support, align, prevent, or correct deformities, or improve the function of a moveable body part.
Orthotist means a person skilled in the construction and application of orthotic equipment.
Outpatient service means services provided to patients at a time when they are not hospitalized as inpatients.
Payer means the employer or self-insured group, carrier, or third-party administrator (TPA) who pays the provider billings.
Pharmacy means the place where the science, art, and practice of preparing, preserving, compounding, dispensing, and giving appropriate instruction in the use of drugs is practiced.
Practitioner means a person licensed, registered, or certified as an acupuncturist, audiologist, doctor of chiropractic, doctor of dental surgery, doctor of medicine, doctor of osteopathy, doctor of podiatry, doctor of optometry, massage therapist, nurse, nurse anesthetist, nurse practitioner, occupational therapist, orthotist, pharmacist, physical therapist, physician assistant, prosthetist, psychologist, or other person licensed, registered, or certified as a health care professional or provider.
Primary procedure means the therapeutic procedure most closely related to the principal diagnosis, and in billing, the code with the highest unit that is neither an add-on code nor a code exempt from modifier 51 shall be considered the primary procedure. Reimbursement for the primary procedure is not dependent on the ordering or re-ordering of codes.
Procedure means a unit of health service.
Procedure code means a five-digit numerical sequence or a sequence containing an alpha character and preceded or followed by four digits, which identifies the service performed and billed.
Properly submitted bill means a request by a provider for payment of health care services submitted to a payer on the appropriate forms with appropriate documentation and within the time frame established under the guidelines of the Fee Schedule.
Prosthesis means an artificial substitute for a missing body part.
Prosthetist means a person skilled in the construction and application of prostheses.
Provider means a facility, health care organization, or a practitioner who provides medical care or services.
Secondary procedure means a surgical procedure performed during the same operative session as the primary surgery but considered an independent procedure that may not be performed as part of the primary surgery.
Special report means a report requested by the payer to explain or substantiate a service or clarify a diagnosis or treatment plan.
Specialist means a board-certified practitioner, board-eligible practitioner, or a practitioner otherwise considered an expert in a particular field of health care service by virtue of education, training, and experience generally accepted by practitioners in that particular field of health care service.
Usual and customary means that when a payment is designated herein as "usual and customary," the amount of the payment equates to the charge value reported by FAIR Health, Inc. in its FH Benchmarks (or other FAIR Health, Inc. Benchmark product available on the date of service) products at the 40th percentile for the applicable geographic area in Mississippi.
20 Miss. Code. R. § 2-IV