(a) All charges for medical and surgical treatment, appliances or
supplies furnished to injured employees, except for treatment and
supplies provided by nursing homes, shall be supported by medical
evidence as provided in Sec. 10.800. The physician or provider shall
itemize the charges on the standard Health Insurance Claim Form, HCFA
1500 or
OWCP 1500, (for professional charges), the UB-92 (for hospitals), the
Universal Claim Form (for pharmacies), or other form as warranted, and
submit the form promptly to OWCP.
(b) The provider shall identify each service performed using the
Physician's Current Procedural Terminology (CPT) code, the Health Care
Financing Administration Common Procedure Coding System (HCPCS) code,
the National Drug Code (NDC), or the Revenue Center Code (RCC), with a
brief narrative description. Where no code is applicable, a detailed
description of services performed should be provided.
(c) The provider shall also state each diagnosed condition and
furnish the corresponding diagnostic code using the ``International
Classification of Disease, 9th Edition, Clinical Modification'' (ICD-9-
CM), or as revised. A separate bill shall be submitted when the employee
is discharged from treatment or monthly, if treatment for the work-
related condition is necessary for more than 30 days.
(1)(i) Hospitals shall submit charges for medical and surgical
treatment or supplies promptly to OWCP on the Uniform Bill (UB-92). The
provider shall identify each outpatient radiology service, outpatient
pathology service and physical therapy service performed, using HCPCS/
CPT codes with a brief narrative description. The charge for each
individual service, or the total charge for all identical services,
should also appear in the UB-92.
(ii) Other outpatient hospital services for which HCPCS/CPT codes
exist shall also be coded individually using the coding scheme noted in
this paragraph. Services for which there are no HCPCS/CPT codes
available can be presented using the RCCs described in the ``National
Uniform Billing Data Elements Specifications'', current edition. The
provider shall also furnish the diagnostic code using the ICD-9-CM. If
the outpatient hospital services include surgical and/or invasive
procedures, the provider shall code each procedure using the proper CPT/
HCPCS codes and furnishing the corresponding diagnostic codes using the
ICD-9-CM.
(2) Pharmacies shall itemize charges for prescription medications,
appliances, or supplies on the Universal Claim Form and submit them
promptly to OWCP. Bills for prescription medications must include the
NDC assigned to the product, the generic or trade name of the drug
provided, the prescription number, the quantity provided, and the date
the prescription was filled.
(3) Nursing homes shall itemize charges for appliances, supplies or
services on the provider's billhead stationery and submit them promptly
to OWCP.
(d) By submitting a bill and/or accepting payment, the provider
signifies that the service for which reimbursement is sought was
performed as described and was necessary. In addition, the provider
thereby agrees to comply with all regulations set forth in this subpart
concerning the rendering of treatment and/or the process for seeking
reimbursement for medical services, including the limitation imposed on
the amount to be paid for such services.
(e) In summary, bills submitted by providers must: be itemized on
the Health Insurance Claim Form (for physicians), the UB-92 (for
hospitals), or the Universal Claim Form (for pharmacies); contain the
signature or signature stamp of the provider; and identify the
procedures using HCPCS/CPT codes, RCCs, or NDCs. Otherwise, OWCP may
return the bill to the provider for correction and resubmission.
