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The official Medical Fee Schedule of the Arkansas Workers’ Compensation Commission shall be based upon the Health Care Financing Administrations’s (HCFA) Medicare Resource Based Relative Value Scale (RBRVS), utilizing HCFA’s national relative value units and Arkansas specific conversion factors adopted by the AWCC. Parties using this schedule should also be familiar with Commission Rule 30, the most current CPT, the Health Care Financing Administration Common Procedure Coding System (HCPCS), and the ASA Relative Value Guide.
This fee schedule shall replace the current AWCC fee schedule on May 15, 2000 and the most current versions of CPT and the Medicare RBRVS shall automatically be applicable upon their effective dates.
This schedule consists of the following sections: Medicine (including Evaluation and Management Services), Surgery, Radiology, Pathology, Anesthesiology, Injections, Durable Medical Equipment, Orthotics, Pharmacy, and Hospital. Providers are to use the section(s) which contain the procedure(s) they perform, or the service(s) they render. Each section has specific instructions or Guidelines. (See Guidelines).
Reimbursement to providers shall be the lesser of the following:
The AWCC Official Fee Schedule can be calculated for any specific CPT code by multiplying the national “fully implemented non-facility total relative value units” (RVUs) by the conversion factor applicable to that CPT.
The conversion factors applicable to this Fee Schedule are as follows:
Anesthesia ………………………………………………………………… $41.76
Surgery………………………………………………………………………. $70.00
Radiology ………………………………………………………………….. $70.00
Medicine…………………………………………………………………….. $44.28
(includes Evaluation and Management Services)
Pathology…………………………………………………………………… $58.28
Pathology codes that do not have RVUs listed in the Medicare RBRVS should be reimbursed 200% of Arkansas Medicare for Clinical Diagnostic Laboratory Fee Schedule allowance, with 30% for the Professional Component and 70% for the Technical Component.
The following forms (or their replacements) should be used for provider billing:
HCFA 1500
UB 92
Bills for reimbursement should be sent directly to the party responsible for reimbursement. In most instances, this is the Insurance Carrier or the Self-Insured Employer. Providers should be able to obtain this information from the employer.
Guidelines define items that are necessary to appropriately interpret and report the procedures and services contained in a particular section and provide explanations regarding terms that apply only to a particular section
The Guidelines found in the most current CPT apply to the following: Evaluation and Management, Medicine, Surgery, Radiology, and Pathology.
In addition to the Guidelines found in the CPT, the following AWCC Guidelines also apply:
Reimbursement shall be based on 100% of the physician’s usual charge for the major procedure (not to exceed 100% of the Medical Fee Schedule allowable) plus 50% of the physician’s usual charge for the lesser or secondary procedure (s) (not to exceed 50% of the Medical Fee Schedule allowable).
Concurrent Care: See Evaluation and Management (E/M) Services Guidelines.
Surgical Assistant: Only a physician who assists at surgery may be reimbursed as a surgical assistant. To identify surgical assistant services, Modifier 80 or 81 should be added to the surgical procedure code which is billed. A surgical assistant must submit a copy of the operative report to substantiate the services rendered. Reimbursement is limited to the lesser of the surgical assistant’s usual charge or 20% of the maximum allowable Fee Schedule amount.
Two Surgeons: For reporting see the most current CPT. Each surgeon must submit an operative report documenting the specific surgical procedure(s) provided. Each surgeon must submit an individual bill for the services rendered. Reimbursement must not be made to either surgeon until the carrier has received each surgeon’s individual operative report and bill. Reimbursement to each surgeon must be made at the provider’s usual charge or the maximum allowable Fee Schedule amount, whichever is less.
The current ASA Relative Value Guide, by the American Society of Anesthesiologists will be used to determine reimbursement for codes that do not appear in the RBRVS. These values are to be used only when the anesthesia is personally administered by an Anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) who remains in constant attendance during the procedure, for the sole purpose of rendering such anesthesia service.
To order the Relative Value Guide, write to the American Society of Anesthesiologists; 520 N Northwest Highway; Park Ridge, IL 60068-2573 or call (847)825-5586.
When anesthesia is administered by a CRNA not under the medical direction of an anesthesiologist, reimbursement shall be 90% of the provider’s usual charge or the ARA, which ever is less. No payment will be made to the surgeon supervising the CRNA.
When anesthesia is administered personally by an anesthesiologist or administered by a care team involving an anesthesiologist and CRNA, reimbursement shall not exceed 100% of the provider’s usual charge or the ARA, whichever is less.
Each anesthesia service contains two value components which make up the charge and determine reimbursement: a Basic Value and a Time Value.
Basic Value relates to the complexity of the service and includes the value of all usual anesthesia services except the time actually spent in anesthesia care and any modifiers. The Basic Value includes usual preoperative and postoperative visits, the anesthesia care during the procedure, the administration of fluids and/or blood products incidental to the anesthesia or surgery and interpretation of non-invasive monitoring (ECG, temperature, blood pressure, oximetry, capnography, and mass spectrometry). When multiple surgical procedures are performed during an operative session, the Basic Value for anesthesia is the Basic Value for the procedure with the highest unit value. The Basic Values in units for each anesthesia procedure code are listed in the current ASA Relative Value Guide.
Anesthesia time starts when the anesthesiologist or CRNA begins to prepare the patient for induction of anesthesia and ends when the personal attendance of the anesthesiologist or CRNA is no longer required and the patient can be safely placed under customary, postoperative supervision. Anesthesia time must be reported on the claim form as the total number of minutes of anesthesia. For example, one hour and eleven minutes equals 71 minutes of anesthesia. The Time Value is converted into units for reimbursement as follows:
Each 15 minutes or any fraction thereof equals one (1) time unit.
Example: 71 minutes of anesthesia time would have the following time units: 71/15 = 5 Time Units.
No additional time units are allowed for recovery room observation monitoring after the patient can be safely placed under customary postoperative supervision.
The total anesthesia value (TAV) for an anesthesia service is the sum of the Basic Value (units) plus the Time Value which has been converted into units. The TAV is calculated for the purpose of determining reimbursement.
Anesthesia services must be reported by entering the appropriate anesthesia procedure code and descriptor into Element 24 D of the HCFA 1500 Form. The provider’s usual total charge for the anesthesia service must be entered in Element 24 F on the HCFA 1500 Form. The total time in minutes must be entered in Element 24 G of the HCFA 1500 Form.
Reimbursement for anesthesia services must be made at the provider’s usual charge or the Anesthesia Reimbursement Allowance (ARA), whichever is less. The ARA is calculated by determining the total anesthesia value for the service rendered and then multiplying that value by an established conversion factor which has a dollar value.
Total Anesthesia Value (Basic Value + Time Value + Physical Status Modifiers when applicable)
X Conversion Factor = ARA
The conversion factor for Arkansas Workers’ Compensation is $41.76
Unusual Circumstances (Modifiers 22, and 23).
Under certain circumstances, the anesthesia service(s) provided may vary significantly from those usually required for the listed procedures. The use of modifiers is appropriate for these instances. The following are modifiers which are commonly used in anesthesia services.
22 Unusual Services: When the service(s) provided is greater than usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure number or by use of the separate five-digit modifier code 09922. A report is required.
23 Unusual Anesthesia: Occasionally a procedure which usually requires either no anesthesia or local anesthesia, because of unusual circumstances, must be done under general anesthesia. This circumstance may be reported by adding the modifier 23 to the procedure code of the basic service or by use of the separate five digit modifier code 09923.
For additional modifiers for physical status and qualifying circumstances see the Relative Value Guide. The use of modifiers does not guarantee additional reimbursement.
When an anesthesiologist or CRNA is required to participate in, and be responsible for, monitoring the general care of the patient during surgery but does not administer anesthetic, such professional services must be billed and reimbursed as though an anesthetic were administered; that is, basic anesthesia plus time.
When an anesthesiologist is not personally administering the anesthesia but is providing medical direction for the services of a nurse anesthetist who is not employed by the anesthesiologist, the anesthesiologist may bill for the medical direction. Medical direction includes the pre and postoperative evaluation of the patient. The anesthesiologist must remain within the operating suite, including the pre-anesthesia and post-anesthesia recovery areas, except in extreme emergency situations. Reimbursement for medical direction by anesthesiologists must be at the provider’s usual charge or 50 percent of the ARA, whichever is less.
When infiltration, digital block or topical anesthesia is administered by the operating surgeon or surgeon’s assistant, reimbursement for the procedure and anesthesia are included in the global reimbursement for the procedure.
When regional or general anesthesia is provided by the operating surgeon or surgeon’s assistant, the surgeon may be reimbursed for the anesthesia service in addition to the surgical procedure.
The operating surgeon must not use the diagnostic or therapeutic nerve block codes to bill for administering regional anesthesia for a surgical procedure.
When an unlisted service or procedure is provided or without specified unit values, the values used should be substantiated “BR” (By Report).
For any procedure or service that is unlisted or without specified unit value, the physician or anesthetist shall establish a unit value consistent in relativity with other unit values shown in the current ASA Relative Value Guide. Pertinent information concerning the nature, extent and need for the procedure or service, the time, the skill and equipment necessary, etc., is to be furnished. Sufficient information should be furnished to identify the problem and the service(s).
of beginning and duration of anesthesia time may require documentation, such as a copy of the anesthesia record in the hospital file.
Supplies and materials provided by the physician over and above those usually included with the office visit or other services rendered may be listed separately. List drugs, tray supplies, and materials provided separately.
Supplies and materials provided in a hospital or other facility must not be billed separately by the physician or CRNA. These charges must be billed by the hospital.
It is appropriate to designate multiple procedures that are rendered on the same date by separate entries.
Reimbursement for injection(s) (such as J codes) includes allowance for CPT code 96372 in addition to wholesale price of each drug. In cases where multiple drugs are given as one injection, only one administration fee is owed.
Surgery procedure codes defined as injections include the administration portion of payment for the medications billed.
J Codes are found in the Health Care Financing Administration Common Procedure Coding System (HCPCS).
Supplies and equipment addressed in this fee guideline will be reimbursed at a reasonable amount. Supplies and equipment not addressed in this fee guideline will be reimbursed at a reasonable amount and coded 99070. All billing must contain the brand name, model number, and/or catalog number. Codes to be used are found in the HCPCS.
The reimbursement for supplies/equipment in this fee guideline is based on a presumption that the injured worker is being provided the highest quality of supplies/equipment. All billing must contain the brand name, model number, and/or catalog number, and a copy of the invoice
Rental fees are applicable in instances of short-term utilization (30-60 days). If it is more cost effective to purchase an item rather than rent it, this must be stressed and brought to the attention of the insurance carrier. The first month’s rent should apply to the purchase price. However, if the decision to purchase an item is delayed by the insurance carrier, subsequent rental fees cannot be applied to the purchase price. When billing for rental, identify with modifier “RT”.
All bills submitted to the carrier for Tens and Cranial Electrical Stimulator (CES) units must be accompanied by a copy of the invoice.
Include the following supplies:
Supplies submitted for reimbursement must be itemized. In unusual circumstances where additional supplies are necessary, use modifier 22 and “BR“.
Limited to 30 days trial period.
Prior to the completion of the 30-day trial period, the prescribing doctor must submit a report documenting the medical justification for the continued use of the unit. The report should identify the following:
The purchase price should include:
Only the first month’s rental price will be credited to purchase price.
Provider will indicate TENs manufacturer, model name, and serial number as shown on invoice.
All TENs units and supplies are listed in the DME list.
Use of this unit in excess of 30 days requires documentation of medical necessity by the doctor. Only one (1) set of soft goods will be allowed for purchase.
Reimbursement for orthotics and prosthetics shall be based on reasonableness and necessity. Orthotics and prosthetics should be coded according to the HCFA Common Procedures Coding System and billed By Report (BR). Copies may be obtained from the American Orthotic and Prosthetic Association, 1650 King Street, Suite 500, Alexandria, VA 22314, (703) 836-7116.
The Pharmaceutical Fee Guideline for prescribed drugs (medicines by pharmacists and dispensing practitioners) under the Arkansas workers’ compensation laws is the lesser of:
The provider’s usual charge; or
The fees established by the formula for brand-name and generic pharmaceuticals as described in subsection (2) of this section.
Prescribed Medication Services
Reimbursement
The pharmaceutical reimbursement formula for prescribed drugs (medicines by pharmacists and dispensing practitioners) is the lesser of:
Average Wholesale Price (AWP) + $5.13 dispensing fee; or the provider’s usual charge.
Reimbursement to pharmacists must not exceed the amount calculated by the pharmaceutical reimbursement formula for prescribed drugs.
A bill or receipt for a prescription drug shall include all of the following:
When a brand name drug is dispensed, the brand name shall be included unless the prescriber indicates “do not label.”
If the drug has no brand name, the generic name, and the manufacturer’s name or the supplier’s name, shall be included, unless the prescriber indicates “do not label.”
The strength, unless the prescriber indicates “do not label.”
The quantity dispensed.
The dosage.
The name, address, and federal tax ID# of the pharmacy.
The serial number of the prescription, if available.
The date dispensed.
The name of the prescriber.
The name of the patient.
The price for which the drug was sold to the purchaser.
The NDC Number (National Drug Code Number).
Determine AWP from the appropriate monthly publication. The monthly publication that shall be used for calculation shall be the same as the date of service. When an AWP is changed during the month, the provider shall still use the AWP from the monthly publication. The publications to be used are:
“Patent” or “Proprietary Preparations”
“Patent” or “Proprietary preparations,” frequently called “over-the-counter drugs,” are sometimes prescribed for a work-related injury or illness instead of a legend drug.
Generic substitution as discussed in A.3. above applies also to “over-the-counter” preparations.
Pharmacists must bill and be reimbursed their usual and customary charge for the “over-the-counter” drug(s).
The reimbursement formula does not apply to the “over-the-counter” drugs and no dispensing fee may be reimbursed.
Dispensing Practitioner
Dispensing practitioners shall be reimbursed the same as pharmacists for prescribed drugs (medicines), except they shall not receive a dispensing fee.
“Patent” or “proprietary preparations” frequently called “over-the-counter drugs,” dispensed by a physician(s) from their office(s) to a patient during an office visit should be billed as follows:
Procedure Code 99070 must be used to bill for the “proprietary preparation” and the name of the preparation, dosage and package size must be listed as the descriptor.
An invoice indicating the cost of the “proprietary preparation” must be submitted to the carrier with the HCFA 1500 Form.
Reimbursement is limited to the provider’s charge or up to 20 percent above the actual cost of the item.
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