The Medical Services Division establishes and monitors billing and payment policies for medical services rendered to workers' compensation claimants and publishes the Medical Services Provider Manual. Division personnel are available Monday through Friday from 8:00 a.m. to 4:30 p.m. to answer questions pertaining to medical billing and payment policy.

Medical Services Provider Manual

Review the Medical Services Provider Manual for information on the Medical Services Provider Manual and instructions on how to place an order.

For additional questions not answered here in the Medical Services Division section, please refer to the Frequently Asked Questions under the Medical Services FAQs.

Injured workers who have concerns about their medical care should contact the Claims Department at 803-737-5723.

Form 14B (posted December 13, 2016) Effective September 1, 2016 MAP $70.

Medical Services Division Advisory Statement

Effective January 1, 2013 - Billing and Payment of Professional Fee Revenue Codes 960 through 999 (PDF)

Medical Bill Dispute Resolution Process

Instructions on filing and resolution of medical billing issues. Please note that submittal of a dispute form must follow proper process and incomplete submittals will not be considered.

2006 Hospital and Ambulatory Surgical Center Payment Manual

The Hospital and Ambulatory Surgery Center Payment Manual describes the billing and payment policy for inpatient hospital stays and outpatient services rendered at a hospital or ambulatory surgical center. Effective October 1, 2006, healthcare facilities will be paid 40% more than the federal Medicare program pays for inpatient and outpatient services. 2006 Hospital and Ambulatory Surgical Center Payment Manual (PDF) Hospital and Ambulatory Payment Manual is updated quarterly as Medicare updates policies and pricing.

Inpatient Hospital

Claims for inpatient hospital stays are paid according to a payment system based on diagnosis related groups (DRGs). DRG is a system of classifying an inpatient stay based on the patient’s diagnosis, medical condition and any procedures performed.  Payments are hospital-specific to account for factors such as rural/urban, number of indigent patients, teaching hospital, etc.

Resources:
Update on "Pass Throughs" (PDF)

Outpatient Hospital

Claims for outpatient services rendered at a hospital are paid based on grouping outpatient services into ambulatory payment classifications (APCs). Services within an APC are similar clinically and require comparable resources. Each APC is assigned a relative payment rate based on the median cost of the services within that classification.   

Ambulatory Surgical Center

Revision Notice: Commission Amends Fee Schedule for Ambulatory Surgery Centers Surgically Implanted Devices (PDF) Ambulatory Surgery Center Fee Schedule for Surgically Implanted Devices Effective April 15, 2013. 

Effective April 15, 2013, the Maximum Allowable Payment (MAP) for procedures performed in an Ambulatory Surgery Center will be calculated at 140% of the Medicare Payment for procedures plus the total cost of all surgical implants per case with Revenue Codes 274, 276, and 278 minus a five hundred ($500) implant cost reduction per case.  Ambulatory Surgery Centers are to utilize the “UB04” for all facility billing.

Claims for ambulatory surgery center services are paid at the Medicare national payment rate found at www.cms.gov/ASCPayment plus 40%.

Note: The multiple procedures rule still applies and the National Correct Coding Initiative will be utilized in order to determine the appropriate billing of CPT and HCPCS codes

 

Contact Information
Bridgette Amick
803-737-5743
bamick@wcc.sc.gov