Ala. Admin. Code r. 480-5-5-.04

Current through Register Vol. 43, No. 1, October 31, 2024

Section 480-5-5-.04 - Statement of Services

(1) A statement of medical services shall be made in accordance with standard coding methodology as established by the ICD-10-CM, HCPCS, and CPT-4 coding manuals and prevailing adjudication rules in Code of Ala. 1975, § 25-5-1(15). Unbundling, fragmenting charges, duplicating, over-itemizing coding, upcoding, unrelated charges, or engaging in any other practice for the purpose of inflating bills for reimbursement shall be prohibited.

(2) Any reference in these Rules to any specific CPT-4 code, HCPCS code, or ICD-10-CM code is not intended to restrict or limit any provider's scope of practice, but is used for clarification only within the context of the specific section in which it appears. When specific codes are used in these Rules, the code reference shall refer to the most current description of the specific code or successor to such code as referenced in the most current edition of the coding manuals described in Rule 480-5-5-04(i).

(3) Medical services shall be billed by the provider using the provider's usual, customary and reasonable charges, although appropriate reimbursement shall be limited to the prevailing reimbursement as ascertained by the Department and published in the most current appropriate provider Maximum Fee Schedule; or as established through negotiated agreements between the Department and participating hospitals; or as established by statutory committee for nonparticipating hospitals; or according to any mutually agreed upon reimbursement in accordance with Code of Ala. 1975, § 25-5-314.

(4) All bills may be subject to audit for verifying services rendered.

(5) Billing for subsequent medical services shall not include repeat billing for medical services previously performed and billed.

Ala. Admin. Code r. 480-5-5-.04

New Rule: Filed August 9, 1996; effective September 13, 1996.

Amended by Alabama Administrative Monthly Volume XXXIV, Issue No. 07, April 29, 2016, eff. 6/10/2016.

Author: Workers' Compensation Medical Services Board

Statutory Authority:Code of Ala. 1975, § 25-5-293.