Changes to Fee Schedule and Billing Guidelines effective October 1, 2000


TO: Commissioners, District Administrators, Self-Insureds, Insurance Carriers, Attorneys, Unions, Medical Practitioners, and Advisory Board Members
FROM: John A. Mastropietro, Chairman
DATE: September 27, 2000
RE: Changes to Fee Schedule and Billing Guidelines effective October 1, 2000


Connecticut General Statute §31-280(b)(26)(A) requires that the Practitioner Fee Schedule and Billing Guidelines be updated each year on October 1. Accordingly, the following changes will become effective October 1, 2000:

  1. The fee for CPT code 97140 is increased to $27.09
  2. The fee for CPT code 98940 is increased to $31.61
  3. CPT code 99455 is deleted from the list of usable codes
  4. Billing Guideline changes detailed on the attachment will become effective

It is my intent to implement the changes for CPT 2001 on January 1, 2001. In order to accomplish this a new set of billing guidelines will be adopted and announced prior to that date. Until then, the billing guidelines effective April 1, 1998 will stay in effect except for the revisions announced in the 1999 update, the 2000 update and the changes included in this memorandum.





(effective October 1, 2000)



FOREWORD (page 1)


Documentation Guideline - Documentation to support levels of service will follow standards developed and published by the Health Care Finance Administration.






E. All payors are required to remit payments to providers on a timely basis. Workers’ compensation payors must remit payment within 60 days of receipt of appropriate documentation for compensable claims. Payments made after the 60th day must include interest payment at the rate of 1.5% per month.



G. For an initial visit, as described by CPT, a complete history including pre-existing conditions and family and systematic history are required. The report must include the following and is required for the initial visit for any new injury to a new body part that occurs to an established patient as well as the initial visit of a new patient:

  1. Treatment plan/recommended course of treatment
  2. Diagnosis and prognosis
  3. Return to work assessment (if possible)
  4. Functionality and work capacity (if possible)
  5. Type and duration of work restrictions (if possible)
  6. Date of next visit

Reports for follow-up visits must include the following:

  1. Return to work assessment
  2. Functionality and work capacity
  3. Type and duration of work restrictions
  4. Referral information
  5. Date of next visit, if necessary
  6. Progress notes

If a final report is required it must include information concerning the attainment of maximum medical improvement, permanency rating and referral information if necessary. This report will be paid at the appropriate level 4 rate. CPT code 99455 should not be used.

Information included in these reports covering the current injury, a pre-existing condition, or historical (previous) information on the same body part as the current injury will be provided to the payor without patient consent. Any other information prior to the date of loss or not related to the same body part will require the patient’s written consent.

Office visits should be billed as defined by CPT. Proper documentation is required for all visits. Any disputes regarding bill coding will be resolved using the guidelines of the HCFA Correct Coding Committee.



C. Pharmacy Reimbursement. Reimbursement for prescription pharmaceuticals ordered for the treatment of work-related injuries/illnesses is as follows:

  1. Average Wholesale Price (AWP) - for the purpose of this fee schedule, AWP refers to the AWP in the current issue of MediSpan Prescription Pricing Guide from First Data Bank or Drug Topics Red Book.
  2. Brand/Trade Name Medications - AWP plus $5.00 dispensing fee
  3. Generic Medications - AWP plus $8.00 dispensing fee

Over the counter medications dispensed by a practitioner’s office will be paid at acquisition price plus 30%.



The use of HCPCS code Q0103 is eliminated. Providers will be allowed to bill for an initial evaluation separate and distinct from any medical treatment provided on that visit and is not included in the $90 daily cap. The initial evaluation will be coded 97001 or 97003. The maximum payment amount for this evaluation will not exceed $90.00. Codes 97002 and 97004 are to be used at the end of a treatment plan in determining any future course of action. The fee for this service is included in the $90 daily cap and should be incorporated in the activity on the final day of the treatment plan.



[NOTE: See Memorandum No. 2000-09 for pertinent information regarding these changes.]

Please note: page numbers on this memo refer to the April 1, 1998 edition of the Official Connecticut Practitioner Fee Schedule as published by Medicode.