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Division of Federal Employees' Compensation (DFEC)

Field Nurse Handbook

Part 9


Part 9 - Billing Requirements and Procedures

Paragraph and Subject

Date

FNHB Trans. No.

Table of Contents

09/13

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1. Overview

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2. The OWCP Central Bill Processing System (CBP) – FN Billing/Reports

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3. Authorization for FN Services

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4. FN Expenditures

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5. FN Procedural Billing Codes

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6. Billing Codes - Telehonic Nurse Assignments

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7. Documenting FN Activities and Expenditures

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8. FN Billing Procedures

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9. FN Reimbursement

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10. FN Billing Invoice Adjustment Procedures

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Exhibit 1 - Billing Codes, Definitions, and Associated Units of Service

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Exhibit 2 - FN Activity Record

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Exhibit 3 - Associated FN Billing Invoice

09/13

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1. Overview. The Division of Federal Employees' Compensation (DFEC) is committed to ensuring prompt and accurate payment for services rendered by the Field Nurse (FN). The Prompt Payment Act requires the Office of Workers' Compensation (OWCP) to pay correctly submitted bills for authorized nursing services within 28 days of receipt. To that end, the OWCP has instituted specific billing procedures and requirements for the processing of FN bills. This Part of the FN Handbook focuses on FN billing requirements and processes.

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2. The OWCP Central Bill Processing (CBP) System – FN Billing/Reports. The OWCP CBP system is the method by which FN billing invoices are submitted and processed for payment. As discussed in Part 8 of this handbook, the CBP system is an automated system that provides the OWCP stakeholders a central domain for the submission and processing of DFEC claims-related medical authorizations and reimbursements/bill payments.

a. The FN should enroll with the OWCP designated bill processing contracted provider to obtain a unique provider identification number (provider ID) prior to billing for any services rendered on behalf of the OWCP/DFEC.

b. The FN should submit all reimbursement requests via the CBP's secure web portal automated bill entry page.

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3. Authorization for FN Services. FN services are subject to a prior authorization system which guides the reimbursement and bill payment process. FN prior authorizations stipulate the FN time and expenditure limits associated with a specific case assignment. The procedures documented below should assist the FN in meeting the requirements of the established prior authorization limits. These prior authorization limits may be adjusted during the course of the nurse intervention period, however, any adjustments to the FN time and/or expenditure limits require discussion with, and written authorization by, the Claims Examiner (CE)/Staff Nurse (SN) prior to rendering continued nurse case management services. See Parts 3, 4 or 5 of this handbook (depending on the type of FN Assignment) and Part 6 for timeframe and/or extension requirements.

a. FN services, including the initial allotted time and expenditure limits, are authorized by the District Office at the time the case is assigned. The FN authorization is transmitted to the CBP prior authorization unit via a secure communication. The CBP prior authorization unit will post this information to the medical authorization site within the CBP system.

b. The FN should verify that prior authorization has been issued for his/her services via accessing the CBP system's medical authorization site prior to any reimbursement/billing entry activity.

c. The FN should document for his/her records the authorized time and expenditure limits associated with a specific assignment and track his/her cumulative progression towards these limits to ensure that no overages occur.

(1) The data entry process for FN billing is subject to real–time error edits. These real-time error edits relate directly to the FN prior authorization information within the CBP system and the automated fee schedule associated with FN billing codes/invoices (the automated fee schedule is discussed in paragraph 8b below). These real-time error edits prevent the FN from moving forward with the data entry process for FN billing.

(2) The error message provides an explanation as to what is preventing the specific billing entry from being accepted. In most instances, real–time error edits may be avoided if the FN has verified his/her prior authorization status before beginning the data entry process for FN billing.

(3) The FN should make note of the error message and contact the SN for assistance if s/he is unable to resolve the error edit and continue with the data entry process for FN billing.

d. FN prior authorizations are issued for each individual case assignment and are identified by the injured worker's (IW's) specific case file number.

e. FN prior authorizations are designated as L808 by the CBP prior authorization unit (and can be viewed in the CBP system's medical authorization site).

f. The FN should not bill for dates of service not authorized in the prior authorization.

g. The FN case charges should not exceed the expenditure limits documented in the prior authorization.

h. The FN should contact the SN in the event that s/he feels the case requires additional expenditure allowances beyond what has already been authorized (and documented in the CBP system's prior authorization). This action should be done proactively, prior to the FN reaching the authorized expenditure limit. The FN is only authorized to provide services within the established pre-authorized limits. See Parts 3, 4 or 5 of this handbook (depending on the type of FN assignment) and Part 6 for timeframe and/or extension requirements.

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4. FN Expenditures. The FN itemizes his/her expenditures based upon the type of activity or service being provided at any given time during the course of an assignment. In addition, the FN should bill in actual time rather than increments or standard charges. The types of FN services are defined below:

a. Professional Services. These services involve the use of professional nursing knowledge, assessment and technical skills. Types of allowable billing for professional services include only the following kinds of nurse case management activities, unless otherwise expressly allowed and pre-approved by the SN:

(1) Contacts. These include face–to-face, telephonic, and/or electronic contacts which address such issues as the IW's status, medical issues, and /or collaboration on appropriate work duties. Specific examples may include:

(a) Meeting/communicating with IWs, medical providers, employing agency personnel, and rehabilitation personnel to facilitate medical recovery and return to work (RTW).

(b) Communicating with all parties, including the CE and/or SN, regarding progress and barriers in reaching the goals and objectives of the nurse case management assignment.

(c) Assisting with preparation for, and arrangement of, medical examinations.

(d) Working with Vocational Rehabilitation Counselors (RC) to facilitate RTW efforts.

(2) Nurse Case Management Reports. Allowable billing for the composition and/or dictation of FN reports is limited to:

(a) Up to 60 minutes for complex or comprehensive reports (usually limited to Initial Evaluations and Catastrophic Case Reports).

(b) Up to 30 minutes for general Progress Reports and Closure Reports.

b. Administrative Services. These services reflect clerical and/or general office-type activities. These activities do not require professional nursing knowledge or skills. Allowable billing for administrative services includes the following types of activities, unless otherwise expressly allowed and pre-approved by the SN:

(1) Preparation/submission of FN reports and billing invoices, including the corresponding activity record – Up to 30 minutes.

(2) Wait time. This refers to any time the FN spends in a medical provider's waiting room as long as the FN is not interacting with the IW and/or performing other billable work activities – Up to 60 minutes.

(a) The FN should bill for only 1 chargeable activity at a time. The FN cannot charge for billable activity on one case file while billing for wait time on another case file.

c. Travel.

(1) The FN should bill mileage at the GSA reimbursement rate, as authorized by the OWCP, for all billable travel miles.

(2) The FN should prorate travel whenever possible. The FN should not charge for round trip transportation on one case file when the transportation was not round trip. For example, if the FN traveled from one location after providing services for a case assignment to another location to provide services on a different case assignment. In this situation, transportation/mileage billing should be parsed between the two case file assignments.

(3) The FN should bill time in transit as an administrative service charge.

(4) Parking costs and toll costs are reimbursed at the actual rate.

d. Non-allowable charges. The FN should not bill for the following:

(1) General mailing or faxing, including postage unless specifically requested by the CE/SN to send a certified, return receipt document.

(2) Advanced payment for medical provider consultations or examinations.

(3) Meals.

(4) Overnight travel expenses unless pre-approved by the SN (if pre-approved by the SN, reimbursement will be paid at the Government's per diem rate).

(5) Research activities including, but not limited to: any electronic or physical method of research the FN may utilize to increase his/her knowledge related to treatment regimens, health conditions/illnesses, and/or any other information that was not specifically requested and pre-approved by the SN.

(6) Time spent on revising or correcting FN Reports, invoices and/or activity records that have been rejected and returned by the SN.

(7) Telephone or cell phone plans.

(8) Long distance telephone charges unless pre-approved by the SN.

(9) Any charges for technology/equipment needed to perform nurse case management activities.

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5. FN Procedural Billing Codes. OWCP has developed procedural billing codes for the explicit use by the OWCP/DFEC Nurse Intervention Program (NIP). Each billing code defines a type of service, with a designated unit of service associated with the specific code. Each billing code has an associated reimbursement rate which has been established and approved by the OWCP National Office. Reimbursement rates are not published, but are provided to the FN at the time of certification.

These are the codes and units of service to be used for calculating the monthly expenditures for all FN charges reflected on the billing invoice. FN expenditures are calculated based upon the reimbursement rates established for each unit of service per given code.

a. Professional Service Charges should reflect codes:

(1) NIP00 – represents professional nurse service charges of 59 minutes or less:

1 minute = 1 unit of service

(2) NIP01 – represents professional nurse service charges in hourly increments:

1 hour = 1 unit of service

b. Administrative Service Charges should reflect codes:

(1) NIA00 – represents administrative services of 59 minutes or less:

1 minute = 1 unit of service

(2) NIA01 – represents administrative service charges in hourly increments:

1 hour = 1 unit of service

c. NITRA – represents the billing code used to request reimbursement of travel mileage, which is reimbursed at the rate established by GSA per mile and authorized by the OWCP.

d. NPART – represents the billing code used to reimburse parking fees and road tolls, which are reimbursed at the actual cost to the FN.

e. NIPTC – represents the billing code used to reimburse long distance telephone call costs, but is only allowable if pre–approved by the SN. The billable amount should equal the actual cost of the call.

1 unit of service = actual fee paid by the FN

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6. Billing Codes - Telephonic Nurse Assignments. There are occasions in which a FN is assigned to a case file and asked to provide only telephonic nurse intervention services, as is discussed in Part 3, paragraph 2a of this handbook. The OWCP uses modified codes to identify and distinguish these types of FN assignments. These billing codes parallel the definitions, limitations and units of services provided in paragraphs 4 and 5 above, with exception to items that involve in-person contact(s) and wait time. The reimbursement rates are consistent with the corresponding NI codes, which are provided to the FN at the time of certification.

a. NCP00 - represents professional nurse service charges of 59 minutes or less:

1 minute = 1 unit of service

b. NCP01 - represents professional nurse service charges in hourly increments:

1 hour = 1 unit of service

c. NCA00 – represents administrative services of 59 minutes or less:

1 minute = 1 unit of service

d. NCA01 – represents administrative service charges in hourly increments:

1 hour = 1 unit of service

e. NIPTC - represents the billing code used to reimburse long distance telephone call costs, but is only allowable if pre–approved by the SN. The billable amount should equal the actual cost of the call.

1 unit of service = actual fee paid by the FN

f. A FN assigned to provide telephonic interventions may not bill for codes NITRA and NPART, in addition to those non-allowable charges outlined in paragraph 4d above.

Exhibit #1 provides a summary of all FN billing codes, definitions and associated units of service.

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7. Documenting FN Activities and Expenditures. The OWCP utilizes an activity record to serve as a detailed accounting of the specific nurse case management activities performed on an individual case assignment during the given reporting/billing period. The activity record not only provides detailed nurse case management activities, but it is also used by the FN to create a summary of the monthly charges to be reflected on the billing invoice. Exhibit #2 provides an example of an activity record.

a. The FN should track nurse case management activities with billable time via an activity record. This activity record is submitted with the associated formal FN report and attached to each billing invoice.

b. The FN should document the activity record with each separate and specific activity including the date of the specific activity, the specific activity performed, the type of service rendered (professional, administrative, etc.), and the amount of the actual time spent on the specific activity.

c. The FN should calculate and document on the activity record the total expenditure per service type. Totals are calculated using the reimbursement rate established for each associated billing code.

d. The FN should utilize the activity record as a reference when converting the charges reflected on the activity record into the itemized summary format for billing invoice submission.

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8. FN Billing Procedures. The FN is held responsible for the accuracy of service- related billing invoices, as stipulated under the procedures set forth herein. Additionally, the FN is subject to the provisions of the False Claims Act (31 U.S.C § 3729) which imposes, in part, liability on any person who submits a claim to the Federal Government that he or she knows (or should know) is false; knowingly submits a false, fictitious or fraudulent record(s) in order to obtain payment from the Government; and/or knowingly obtains money from the Federal Government to which he or she is not entitled, and uses false statements or records in order to retain the money.

a. FN charges are submitted on a monthly basis using the designated CBP system's electronic bill entry page (herein referred to as a billing invoice), which is accessed via a secure web portal.

(1) FN requests for payment should be made by charging individual case files for nurse case management activities performed during a specified timeframe/reporting period (e.g. usually every 30 days from the date of case assignment).

(2) The FN should submit a scheduled, formal FN report and associated detailed activity record with each billing invoice. These documents should be attached to, and transmitted with, the billing invoice via the web portal. See Part 6 of this handbook for FN reporting requirements.

(3) The dates of service reflected on the billing invoice should correspond to the service period documented on the associated FN report and activity record.

(4) A FN billing invoice should exclude any date of service billed during a prior billing/reporting period. There should be no overlap in dates of service from a previous billing/reporting period.

(5) FN billing invoices should reflect a summary of the professional, administrative, and ancillary charges as detailed on the associated activity record using the procedural billing codes defined above. Each procedural billing code should be used only one time per billing invoice period. Exhibit #3 provides an example of a billing invoice, using the associated Exhibit #2 activity record.

(6) A FN billing invoice should reflect charges inclusive of only those billable nurse case management activities documented on the associated report/activity record.

b. FN case management services/activities are subject to a fee schedule which is incorporated into the automated CBP system. In addition to the total case file assignment timeframe allotments and the total case file assignment expenditure limits reflected in the FN nurse prior authorization, there are also limits imposed on the total allowable time spent on each case per reporting/billing period.

(1) FN charges should not exceed a total of 15 professional hours per reporting/billing period without receiving consent and prior authorization from the CE/SN.

(2) FN charges should not exceed a total of 15 administrative hours per reporting/billing period without receiving consent and prior authorization from the CE/SN.

See Parts 3, 4 or 5 of this handbook (depending on the type of FN assignment) and Part 6 for timeframe and/or extension requirements.

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9. FN Reimbursement. Reimbursement is issued to the FN upon the SN review and approval of the submitted documents (FN report, activity record and billing invoice), and the successful processing of the billing invoice through the CBP system.

a. The SN has the authority to return to the FN any billing invoices and/or reports that s/he determines are incomplete or incorrect, or when the charges do not correlate with the documented nurse case management activities. The documents are returned to the FNs via the web portal.

(1) The SN should return to the FN all documents associated with the submitted billing invoice. The OWCP policy does not allow for the acceptance and processing of individual items that are submitted as part of the reimbursement request package. A billing invoice will be processed only upon the acceptance of an approved FN report and activity record; a FN report and activity record will be accepted only upon approval of the associated billing invoice.

(2) The FN should review the returned documents and make the necessary modifications (changes, clarifications and/or corrections) as identified in the explanation of return. These modifications should be made to the existing document(s). It is not necessary, or advisable, for the FN to create a new billing invoice document for items that require modification.

b. Upon approval by the SN, the billing invoice and related documents are processed into the CBP system where the billing invoice is subject to an automated review and audit for quality assurance purposes. The related documents (FN report and activity record) are then automatically uploaded to the case file/record.

(1) Some billing invoices approved by the SN may not pass the post- approval audit that is incorporated into the CBP's automated system. This may result in partial or no payment for a particular billing invoice. The FN will receive notification from the CBP system, which is referred to as a Remittance Voucher (RV)/Explanation of Benefits (EOB) form, which provides a line item description of charges per case, the amount reimbursed for each line item, and an explanation as to why some/all of the submitted charges were not reimbursed.

(2) The FN should review all RVs/EOBs to ensure appropriate payment has been issued. In the event a discrepancy is noted, the FN should proceed with submitting a billing invoice Adjustment Request form as discussed in the next paragraph.

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10. FN Billing Invoice Adjustment Procedures. Despite meticulous attention to data input by the FN and careful review by the SN, billing errors may still occur resulting in an inaccurate reimbursement or denial of submitted charges. The OWCP has instituted a billing invoice adjustment process unique to the NIP to facilitate timely correction and expedient reimbursement of any outstanding billing issues.

a. The FN should complete a billing invoice Adjustment Request form which identifies the error, provides rationale why s/he believes the reimbursed amount is incorrect, and indicates the balance due for reimbursement. As these Adjustment Request forms are exclusive to the OWCP NIP, they are not published but are provided to the FN at the time of certification.

b. The FN should submit the completed Adjustment Request form along with supporting documentation (associated RV/EOB form) to the SN.

c. Upon review and approval of the requested adjustment, the SN should sign the Adjustment Request form and submit it to the CBP unit via the designated fax line in order for payment to be issued promptly.

d. Adjustment Requests should be submitted within 30 days of the issue date of the RV/EOB that reflects a reimbursement discrepancy.

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Exhibit 1 - FN Billing Codes, Definitions, and Associated Units of Service

NIP00 = professional time reflected in minutes; 59 or less:

1 unit = 1 minute

NIP01 = professional time reflected in hourly increments:

1 unit = 1 hour

NIA00 = administrative time reflected in minutes; 59 or less:

1 unit = 1 minute

NIA01 = administrative time reflected in hourly increments:

1 unit = 1 hour

NITRA = number of miles traveled:

1 unit = 1 mile

NPART = parking fees and road tolls:

1 unit = actual charge paid by FN

NIPTC = pre-approved long distance telephone calls:

1 unit = actual charge for individual call

Telephonic Assignment Codes:

NCP00 = professional time reflected in minutes; 59 or less:

1 unit = 1 minute

NCP01 = professional time reflected in hourly increments:

1 unit = 1 hour

NCA00 = administrative time reflected in minutes; 59 or less:

1 unit = 1 minute

NCA01 = administrative time reflected in hourly increments:

1 unit = 1 hour

NCPTC = pre-approved long distance telephone calls:

1 unit = actual charge for individual call

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Exhibit 2 - FN Activity Record

DATE

SERVICE

Professional
minutes

Admin.
minutes

Parking/tolls

NITRA
(MILEAGE)

11/15/12

TC to IW LM

NC

     

11/29/12

TC to IW

15

     

11/29/12

TC to Dr. office

10

     

11/29/12

TC to PT

15

     

12/01/12

Rec/rev PT notes

15

     

12/01/12

Rec/rev Dr. report

15

     

12/08/12

Mtg @ Dr. office

15

60 (travel)

 

40

12/08/12

TC to IW LM

NC

     

12/08/12

TC to PT

10

     

12/08/12

TC to EA

10

     

12/08/12

TC from IW

10

     

12/08/12

Progress (complex)
Report

50

30

   
           
 

Total minutes

165

90

   
 

Professional time

165/60 = 2.75
Hr.

     
 

Admin. Time

 

90/60 = 1.5
Hrs.

   
   

NIP00

NIP01

NIA00

NIA01

NPART

Mile.

               
 

Total Time per charge

45

2

30

1

 

40

 

Cost:

X 1.25

X 75.

X 0.63

X 38.00

 

X 0.445

   

56.25

150.00

18.90

38.00

 

17.80

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Exhibit 3 - Associated FN Billing Invoice

Line

Date from

Date to

Procedure
Code

Units

Charge per
unit

total

1

11/15/2012

12/8/2012

NIP00

45

1.25

56.25

2

11/15/2012

12/8/2012

NIP01

2

75.00

150.00

3

11/15/2012

12/8/2012

NIA00

30

0.63

18.90

4

11/15/2012

12/8/2012

NIA01

1

38.00

38.00

5

11/15/2012

12/8/2012

NITRA

40

0.45

17.80

Total
Charges

 

 

 

 

 

280.95

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