Chart View: Mich. Procedure Code & Modifiers (Plus Table 10904)

Birmingham. MI (WorkersCompensation.com) -- In Michigan, a healthcare service must be billed with procedure codes adopted from "Current Procedural Terminology (CPT®) 2023 Professional Edition" or "HCPCS 2023 Level II Professional Edition," as referenced in R 418.10107. Procedure codes from the CPT code set are not included in these rules but are provided on the agency’s website at www.michigan.gov/leo/bureaus-agencies/wdca. "Current Procedural Terminology (CPT®) 2023 Professional Edition" contains standard billing instructions.

A provider billing services described with procedure codes from "HCPCS 2023 Level II Professional Edition" shall refer to the publication as adopted by reference in R 418.10107, for coding information.

Who has to bill codes from "HCPCS 2023 Level II Professional Edition"?

(1) Ambulance providers.
(2) Certified orthotists and prosthetists.
(3) Medical suppliers, including expendable and durable equipment.
(4) Hearing aid venders and suppliers of prosthetic eye equipment.
(5) A home health agency.

If a practitioner performs a procedure that cannot be described by one of the codes listed in the most recent publication entitled “Current Procedural Terminology (CPT®)” or “HCPCS Level II,” the practitioner shall bill the unlisted procedure code. An unlisted procedure code must only be reimbursed when the service cannot be properly described with a listed code and the documentation supporting medical necessity includes all of the following:

(1) Description of the service.
(2) Documentation of the time, effort, and equipment necessary to provide the care.
(3) Complexity of symptoms.
(4) Pertinent physical findings.
(5) Diagnosis.
(6) Treatment plan.

A provider has to add a modifier code following the correct procedure code describing unusual circumstances arising in the treatment of a covered injury or illness. When a modifier code is applied to describe a procedure, a report describing the unusual circumstances must be included with the charges submitted to the carrier.

Applicable modifiers from table 10904 must be added to the procedure code to describe the type of practitioner performing the service. The required modifier codes for describing the practitioner are, as follows:

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