Private Hospital Invoicing Guidelines

The Victorian WorkCover Authority (VWA) will pay the reasonable cost of private hospital services required as a result of a work-related injury or illness.

What is a private hospital?
What is a private hospital service?
How much will the VWA pay?
When will the VWA pay for private hospital services?
What will the VWA pay for?
- included in the bed fee
- in addition to the bed fee
What won’t the VWA pay for?
Are there any exceptions?
What Accommodation Classifications does the VWA use?
Is prior approval required?
How does the VWA calculate private hospital theatre fees?
How does the VWA calculate the number of days in hospital?
Transfers between acute care episodes and rehabilitation
Continuous periods of hospitalisation and step-downs
What are the guidelines for Admission and Re-admission?
What are VWA’s Minimum Invoicing Requirements?

What is a private hospital?
A private hospital is:

A private hospital within the meaning of the Health Services Act 1988, or a private hospital within the meaning of the section 178 of the Health Act 1958; or,
A private hospital within the meaning of a law of another State or of a Territory; or,
A private hospital outside Australia approved by the VWA.

What is a private hospital service?
“Private hospital service” means the provision by a private hospital of:

Medical care and treatment (See What the VWA will Pay For);
Nursing care and treatment;
Medicines, medical, surgical and other curative materials, appliances or apparatus; and
Any other usual or necessary services provided by a hospital with respect to the treatment of the injury or disease of the injured worker.

How much will the VWA pay?
The VWA will pay the reasonable cost of private hospital services in accordance with the VWA fee schedules.

Victorian Private Hospitals
The VWA will pay Victorian private hospitals in accordance with their relevant fee schedule.
Interstate and Overseas Private Hospitals
The VWA will pay interstate and overseas private hospitals in accordance with the VWA non-arrangement private hospital fee schedule.

When will the VWA pay for private hospital services?
The VWA will pay for the reasonable cost of private hospital services where:

the provision of the service is for a work-related injury or illness; and
the service is necessary in the circumstances; and
there has been a referral from a medical practitioner; and
approval has been provided by the WorkCover Agent; and
the private hospital is registered with the VWA to provide private hospital services.

What will the VWA pay for?
The following private hospital goods and services are included in the bed fee:

Accommodation in a shared ward:
- Circumstances warranting a private room are very infrequent. The WorkCover Agent will consider community standards when reviewing these requests (i.e. would a similar non-compensable patient be expected to be adequately clinically managed in a shared ward);
- Private room charges will only be considered where a medical practitioner certifies that the private room is clinically necessary and prior approval has been provided by the WorkCover Agent; and
- Payment for any ‘private room add on fee’ not approved by the WorkCover Agent is the responsibility of the hospital or injured worker as negotiated by them prior to admission in the informed financial consent process.
Admission information and copies of operation and discharge summaries;
Equipment (aids and appliances) required during the private hospital episode;
Dietary requirements incl. meals, naso-gastric feeds, dietary supplements and vitamins;
Medication intrinsic to the private hospital episode for conditions related to the work-related injuries or illnesses;

See also:
• The VWA will pay for the following private hospital services in addition to the bed fee: - Medication on discharge; and
• The VWA pharmacy policy

Nursing services provided in hospital; and
Any other usual or necessary services provided by a hospital with respect to the treatment of the injury or disease of the injured worker.

The VWA will pay for the reasonable cost of the following private hospital goods and services in addition to the bed fee:

Treatment in the emergency department of a private hospital.
- Treatment provided to injured workers by registered medical practitioners working in the emergency department can be charged on a fee-for-service basis in accordance with the VWA reimbursement rates for medical services.
A facility fee will be reimbursed to cover material and administration costs of services provided during an emergency attendance in an approved private hospital emergency department.
- Only one emergency department facility fee is payable per injured worker per emergency department attendance when the patient is not admitted to hospital.
- Where the injured worker is admitted to the hospital from the emergency department, no facility fee is payable unless the admitting hospital is different from the hospital providing the emergency department service.
Medications (up to one month’s supply) which are dispensed on discharge and that are intrinsic to the treatment of the work related injury for which the injured worker is receiving hospital treatment, and provided in accordance with the VWA pharmacy policy;
Equipment (aids and appliances )provided at discharge which relate to the hospital episode and are provided in accordance with the VWA ‘Aids and Appliances Policy’
- Equipment must reasonably be required to ensure the workers functional recovery immediately after discharge;
- Equipment requirements must be documented on the worker’s discharge summary and plan; and
- All equipment requests must be approved by the WorkCover Agent prior to discharge from the private hospital
Medical treatment provided by a registered medical practitioner. This includes medical treatment, radiology and pathology provided by medical officers employed or contracted by the hospital to provide the services.
Theatre fees are inclusive of all disposables and consumables required for operating room procedures unless otherwise indicated in the National Procedure Banding Recommendations and List published by the Australian Private Hospital Association (APHA).

Prostheses List items provided in accordance with the VWA Prosthesis Policy for Private Hospitals and Elective Surgery Policy:
- The VWA will pay the reasonable cost of prostheses which are listed on the Commonwealth Department of Health and Ageing (DoHA) Prosthesis List. The prosthesis item code must be included on the invoice for payment (Refer to the Prostheses List on the DoHA website under ‘Arrangements for listing and setting benefits for prostheses’
- The VWA will pay up to the maximum benefit listed for each item on the Prosthesis List;
- If the item is designated a ‘gap’ item on the Prosthesis List, a written clinical rationale for the use of that specific item will be required from the surgeon at the time of the elective surgery request (refer to the VWA Elective Surgery Policy) in order for the request to be considered by the WorkCover Agent; and
- The WorkCover Agent will consider the reimbursement of prostheses not covered by the VWA Prosthesis Policy for Private Hospitals on a case by case basis. The surgeon, assisted by prosthesis supplier must provide the WorkCover Agent with adequate information to enable them to make an informed assessment and decision
Travel for inpatients from one private hospital to receive medical services at another facility for their work-related injury or illness, or to attend an approved outpatient service provided in accordance with the VWA’s travel policy (see VWA travel policy).
- This transport may be via ambulance, taxi or other appropriate service
- The clinical need for the transport should be validated by the treating medical practitioner and prior approval given by the WorkCover Agent.
- This excludes the cost of Nursing or Medical personnel to escort the injured worker, unless clinically necessary and approval has been given by the WorkCover Agent.
Interpreter services required by an inpatient or outpatient for the purposes of adequately receiving the required treatment.
Medications (up to one month’s supply) which are dispensed on discharge and that are intrinsic to the work-related injury for which the injured worker is receiving hospital treatment, and provided in accordance with the VWA Pharmacy Policy; and
Outpatient services that have been approved by the injured workers WorkCover Agent.

What won’t the VWA pay for?
The VWA will not pay for the following private hospital goods and services:

Attendant and personal care;
Emergency department facility fee where the emergency attendance results in a private hospital admission;
Disposables and consumables required for operating room procedures, as these are considered to be included in the theatre fees (unless otherwise specified by the current National Procedure Banding Committee (NPBC) recommendations published by the APHA;
Goods and services unrelated to the workplace injury or condition, including medications extrinsic to the hospital admission;
Incidentals such as newspapers and personal toiletries (e.g. toothpaste, soap);
Nursing or Medical personnel to escort an injured worker when travelling from one private hospital to receive medical services or to attend an approved outpatient service at another facility for their work-related injury or illness, unless the escort is clinically necessary and approval has been given by the WorkCover Agent;
Outpatient services not approved by the injured worker's WorkCover Agent;
Private room charges;

Telephone and television charges; and
Visitors’ meals and accommodation.

Are there any exceptions?
Requests for private hospital services not covered under the Private Hospital Policy or the Private Hospital Invoicing Guidelines will be assessed by the WorkCover Agent on a case by case basis. The assessment will consider the reasonableness and the work-relatedness of the request, including other VWA policies and community standards. The private hospital must provide the WorkCover Agent with adequate information to enable them to make an informed assessment and decision.

What Accommodation Classifications does the VWA use?
An injured worker's private hospital accommodation classification is determined by the ICD-AM-10 v5 code and/or MBS code that best clinically describes the private hospital admission or surgical procedure relevant to their work-related injuries / illnesses.

The VWA uses the following classifications to categorise the worker’s accommodation where the stated conditions apply:

Advanced Surgical (AS), and General Surgical (GS)
(See also the VWA Medical Practitioner Services Policy)

a. The AS and GS categories are for surgical patients only and the categories are determined by the cost corresponding to the MBS item number relevant to the surgical procedure performed. MBS item numbers above the DoHA determined dollar threshold are categorised as ‘AS’, and MBS item numbers below the DoHA determined dollar threshold are categorised as ‘GS’;

b. When an item number is not included in the MBS schedule, a worker will be classified as Medical;

c. The VWA will only pay surgical bed fees up to 24 hours prior to the date on which the surgical procedure is performed. Periods of hospitalisation prior to this will be reimbursed at a medical bed rate as determined by the ICD-AM-10 v5 code relevant to the work-related injuries or illnesses being treated; and

d. Where the requested and approved surgical procedure requested differs from that actually performed, the WorkCover Agent may require a copy of the operation report.

Multiple Surgical Procedures on the same day
(AS and GS accommodation classifications)

When a worker undergoes more than one surgical procedure on the same day, the accommodation classification for the total period of hospitalisation will be determined by the surgical procedure with the highest MBS fee.

Multiple Surgical procedures on different days during the same period of hospitalisation
(AS and GS accommodation classifications)

Where there are multiple surgical procedures on different days during the same period of hospitalisation:

If the MBS item fee for the subsequent surgical procedure falls within a higher accommodation classification (AS) than the initial procedure (GS), then a new accommodation step-down will commence from the date of the subsequent procedure.

Example:
Admitted to hospital 1 September
General Surgical procedure performed 1 September
Advanced Surgical procedure performed 5 September

* From 1 to 4 September = General Surgical Patient classification (4 days)

* From 5 to 18 September = Advanced Surgical Patient classification (14 days)

Note: 1 When this occurs it is essential that accounts show separate inpatient periods for each patient classification.

If the MBS item fee for the subsequent surgical procedure falls within a lower accommodation classification (GS) than the initial procedure (AS), then the original accommodation step-down period continues.

Example:
Admitted to hospital 1 September
Advanced Surgical procedure performed 1 September
General Surgical procedure performed 5 September

* From 1 to 4 September = Advanced Surgical Patient classification (4 days)
* From 5 September = Advanced Surgical Patient classification continues

Day Surgery (DS)
a. Day surgery patients are patients who are admitted and discharged on the same day, and where a surgical procedure listed on the DHA MBS ‘Same day’ or ‘Day Only’ (Type B or certified Type C categories) has been performed.

b. Medical practitioner certification is required by the WorkCover Agent for any Day surgery patient who subsequently requires overnight or longer accommodation (in accordance with DoHA rules for Type B and Type C MBS procedures). The certification must include the ICD-AM-10 v5 code relevant to the injury or condition being treated, and the medical condition or special circumstances warranting overnight care.

c. Theatre procedures are reimbursed at the appropriate theatre band.

d. The VWA uses 4 Day Accommodation bands (i.e. band 1, 2, 3 or 4) which apply to the accommodation component of defined (DoHA) Day Only MBS items. Accommodation bands for ‘day surgery’ cases are paid depending on the type of anaesthetic used during the surgical procedure and the time taken in the operating theatre according to the following rules:

Band 1 day accommodation is payable where a procedure is performed with no anesthetic.

Band 2 day accommodation is payable where procedures (other than Band 1) are carried out under local anaesthetic, without sedation.

Band 3 day accommodation is payable where procedures (other then Band 1) are carried out under general or regional anaesthetic or IV sedation and the theatre time (actual time in theatre) less than I hour.

Band 4 day accommodation is payable where procedures (other than band 1) are carried out under general or regional anaesthesia or intravenous sedation and actual theatre time that is time taken in theatre is more than one hour.

e. Non-Band Specific (DoHA defined) classes of MBS items will qualify for Day Only Accommodation bands depending on anaesthetic and theatre times. In the absence of a theatre time, the VWA will only pay a band 1 ‘day only’ accommodation charges.

f. ‘Day Only’ Accommodation Bands are not payable for DoHA Type C Professional Attention MBS items unless medical certification is provided.
Medical (M)

a. Injured workers who are admitted to hospital as Medical patients (M) must have the ICD-AM-10 v5 codes relevant to their work-related injuries or illnesses that have resulted in their admission to hospital, on the invoice.

b.The fees that can be charged for a Medical patient are those on the VWA private hospital fee schedules.

Change of classification during an admission.
(M to AS or GS accommodation classifications during the same admission)

If the injured worker is admitted as a Medical patient on one day and subsequently (on another day) undergoes a surgical procedure (other than a defined Day Only Procedure), the accommodation classification and associated accommodation fee changes from medical (M) to surgical (AS or GS) on the day that the MBS procedure or surgery is performed. Fees are charged in accordance with the class on the VWA fee schedule.

Note: It is essential that accounts show separate inpatient periods for each patient classification.

Example:

Admitted to hospital 3 December as Medical classification

Surgery performed on 7 December

* From 3 December to 6 December = Medical Patient classification (4 days)

* From 7 December to 14 December = Surgical Patient classification ( 8 days)

Intensive Care or Coronary Care

a. The Intensive Care Unit (ICU) and Coronary Care Unit (CCU) classifications only apply to private hospitals who have an ICU or CCU which is approved by the Department of Human Services Victoria.

b. When calculating ICU and /or CCU payments as part of a private hospital episode, the overall inpatient bed days are taken into account from admission to discharge.

c. ICU/CCU rates are payable up to a maximum of four days in an ICU/CCU per hospital admission. Periods in an ICU/CCU are not taken into account in calculating bed-day counts for step-down purposes.

d. If the VWA’s ICU/CCU bed day count is exceeded, the payment will revert to the daily payment rate aligned with the workers medical or surgical classification.

e. If additional ICU/CCU bed days are required in excess of the number stated in the fee schedule, additional clinical information supporting the need for ongoing accommodation in critical care should be provided to the injured workers’ WorkCover Agent as soon as possible after admission.

Psychiatric Inpatient

a. A psychiatric patient is an injured worker in a hospital who, subject to approval from the WorkCover Agent, is admitted for the purpose of undertaking a specific psychiatric treatment program.

b. The admitting psychiatric private hospital must receive prior approval of the admission from the WorkCover Agent in order to be reimbursed.

c. The pre-approval conditions do not apply where the worker is admitted to private hospital for emergency treatment of work-related injuries or illnesses, including those that are life threatening and would otherwise result in death. In such cases, approval should be obtained as soon as possible after admission by contacting the employer or WorkCover Agent.

d. When requesting prior approval, the admitting private hospital should provide the WorkCover Agent with details of:

The workers diagnosis and its relationship with the work-related injuries or illnesses;
The estimated term of inpatient stay;
The accommodation type using VWA item codes;
The estimate of fees for the inpatient stay.

e. The psychiatric bed fees include all types of therapies provided to the worker but excludes medical services provided by registered medical practitioners.

f. The VWA will pay electroconvulsive therapy in addition to the accommodation fee, provided prior approval has been obtained from the WorkCover Agent.

Rehabilitation

a. A rehabilitation patient is an injured worker who, subject to the approval of their WorkCover Agent, is admitted for the purpose of undertaking a specific rehabilitation treatment program.

b. The admitting rehabilitation private hospital should ensure that liability for the service has been accepted by the WorkCover Agent before the rehabilitation admission occurs.

c. The admitting private hospital should provide the WorkCover Agent with the following documents to enable it to determine the reasonableness of the admission:

Medical Practitioner referral for rehabilitation
Treatment plan including functional assessment
Anticipated duration of hospitalisation
The costs associated with the admission

d. The VWA will pay the rehabilitation rate published in the VWA schedule of fees, as determined by the patient’s primary ICD-AM-10 v5.
Outpatient Rehabilitation services
- The VWA will pay outpatient rehabilitation services on a fee-for-service basis, as specified in the relevant VWA fee schedule.
- The rehabilitation private hospital should ensure that the service(s) have been approved by the Agent before the rehabilitation service(s) commence. The private hospital should provide the Agent with the following documents to assist them in determining the reasonable cost of the service(s):
1. Medical Practitioner referral for rehabilitation;
2. Treatment plan and functional assessment scores;
3. Anticipated duration of treatment;
4. The costs associated with the rehabilitation treatment.

Is prior approval required?
Prior written approval for the liability of the private hospital goods and services is required from the WorkCover Agent prior to the provision of the service. Prior written approval for liability ensures that the private hospital provider will be reimbursed for the service provided.

The prior approval conditions do not apply where the injured worker is admitted to private hospital for emergency treatment of work-related injuries or illnesses including those that are life threatening. In such cases, approval should be obtained as soon as possible after admission by contacting the employer or WorkCover Agent.

How does the VWA calculate private hospital theatre fees?
Please note that all medical practitioner fees (either medical or surgical) are billed separately from private hospital fees. (See also the VWA MBS rules, and the VWA Elective Surgery Policy)

The VWA pays a theatre fee based on the band number allocated to the applicable MBS item/s as per the National Procedure Banding List published by the Australian Private Hospital Associations (APHA)(see table below).

The VWA considers that the theatre fee covers the cost of all consumables, disposables and drugs required during a procedure, for the actual procedure and/or anaesthetic unless otherwise indicated in the National Procedure Banding Committee (NPBC)List or the NPBC recommendations.

Multiple operations
The ‘multiple theatre rule’ is to be applied per occasion of theatre. For multiple operations during the same occasion of theatre, a sliding scale is used to calculate the theatre rebate. For separate visits to theatre on the same day, the sliding scale applies independently to each occasion of theatre.

The VWA will reimburse theatre fees for multiple operations as follows:

Type of Procedure	% paid
Highest Banded MBS procedure	100%
Next highest procedure	50%
Third and subsequent procedures	33%

How does the VWA calculate the number of days in hospital?

The day of admission to private hospital is counted as day one of the inpatient episode. Inpatient bed days are calculated on the number of nights (that is the time past midnight) spent in hospital.

Transfers between acute care episodes and rehabilitation

The rehabilitation component of the acute episode will be considered a continuation of the acute care episode and as such, acute step-downs will apply if there is no pre-approval for the rehabilitation component.

What are the guidelines for Admission and Re-admission?

VWA considers that private hospital admissions and rehabilitation programs are continuous and as such, the day count continues:

after short periods of absence up to seven days or less;
regardless in change of rehabilitation classification or ho.spital

If the admission or program is interrupted then resumed, the following guidelines apply:

Discharge and readmission is within seven days

The day count toward step-down for the initial private hospital admission will continue taking into account the previous days spent in hospital for an injured worker who is re-admitted to a private hospital, for the same condition (same ICD-AM-10 v5 diagnosis), within seven days from the previous date of discharge (either to the same or a different hospital). Medical certification may be required by WorkCover Agent to support the need to interrupt a planned admission or program of rehabilitation.

Re-admission is eight or more days from the previous date of discharge

A new day count will commence from the first day of the re-admission when the re-admission is eight or more days after the previous date of discharge. The worker classification will be determined by the work-related injuries or illnesses treated during the re-admission.

What is VWA’s Minimum Invoicing Requirements?
To facilitate prompt payment of WorkCover accounts, invoices must include:

Invoice and hospital details

Invoice number
Date of invoice
Hospital name, address and provider number

Injured worker details

Name and address
Claim number
Date of birth

Admission and treatment details

Date of service - including admission and discharge dates
ICD-AM-10 v5 diagnosis codes (primary and a minimum of 5 secondary where appropriate) relating to any work-related injuries and illnesses treated during the private hospital episode, including a description (refer to ICD-AM-10 v5 notes below)
MBS procedure codes and a description of the procedures performed (where surgery is performed)
Theatre band based on the National Procedure Banding Committee ( NPBC) List managed by the Australian Private Hospital Associations (APHA) and NPBC recommendations (where surgery is performed)
Prostheses Codes, description and cost
Consumables and Disposables only when recommended for reimbursement by the NPBC
VWA accommodation classification as per the VWA private hospital fee schedule
Itemised list of discharge medications intrinsic to the work related injury for which the injured worker is admitted to hospital
A description of the service(s) and fee(s) charged

Note: ICD-AM-10 v5 codes

The VWA will only pay accounts that quote the ICD-AM-10 v5. AM primary and secondary diagnosis codes (minimum of five) and relate to work-related injuries or illnesses treated during the private hospital episode, including a summary description. MBS procedure codes and descriptions must also be supplied.

For example, where a worker is having spinal fusion surgery, the private hospital must provide the ICD-AM-10 v5 code relating to the actual injury which is being treated by the surgery i.e. chronic low back pain, disc degeneration etc.

Accounts may also quote procedure codes (i.e. spinal fusion surgery), but only as a supplement to the primary ICD-AM-10 v5 codes (the MBS procedure code MUST also be provided).

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