No. 40818 (Amendment): Section R612-300-4. General Method for Computing Medical Fees

(Amendment)

DAR File No.: 40818
Filed: 09/22/2016 03:00:06 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this amendment is to adopt, with modifications, the Optum 2016 Essential Resource-Based Relative Value Schedule (RBRVS), 2016 1st Quarter Emergency Update and the 2016 American Medical Association Current Procedural Terminology (CPT) coding standards, to specify the effective date of the rule as being 12/01/2016, and to adjust the conversion factors regarding certain medical specialties.

Summary of the rule or change:

The amendment incorporates by reference current versions of the RBRVS and adjusts the conversion factors related to the practice of anesthesiology from $53 to $57 per unit.

Statutory or constitutional authorization for this rule:

• Section 34A-2-201
• Section 34A-1-104

This rule or change incorporates by reference the following material:

• Updates The Essential RBRVS, published by Optum 360, 2016
• Updates Current Procedural Coding Expert, published by Optum 360, 2016

Anticipated cost or savings to:

the state budget:

The proposed amendment will impose no additional administrative or enforcement costs on the Labor Commission, which is the state agency charged with administering and enforcing Utah's workers' compensation system. The National Council on Compensation Insurance projects that overall workers' compensation costs will increase by 0.1% as a result of adoption of the new conversion factor. The Commission presumes that this increase will be passed on to the state in increased workers' compensation insurance premiums. The exact costs cannot be determined since workers' compensation premiums are unknown.

local governments:

The National Council on Compensation Insurance projects that overall workers' compensation costs will increase by 0.1% as a result of adoption of the new conversion factor. The Commission presumes that this increase will be passed on to local governments in increased workers' compensation insurance premiums. The exact cost cannot be determined since workers' compensation premiums are unknown.

small businesses:

The National Council on Compensation Insurance projects that overall workers' compensation costs will increase by 0.1% as a result of adoption of the new conversion factor. The Commission presumes that this increase will be passed on to all employers, including small businesses, in increased workers' compensation insurance premiums. The exact cost cannot be determined since workers' compensation premiums are unknown.

persons other than small businesses, businesses, or local governmental entities:

The National Council on Compensation Insurance projects that overall workers' compensation costs will increase by 0.1% as a result of adoption of the new conversion factor. The Commission presumes that this increase will be passed on to all employers, including small businesses, in increased workers' compensation insurance premiums. The exact cost cannot be determined since workers' compensation premiums are unknown.

Compliance costs for affected persons:

Workers' compensation insurance carriers and those providing medical services to injured workers will be affected by the proposed amendment. Because the RBRVS and CPT systems are already used throughout the health care industry, insurance carriers and medical providers already receive and use updates to those systems. The Commission does not anticipate that the updates required by this rule amendment will result in any additional compliance costs for those entities. The exact cost cannot be determined since workers' compensation premiums are unknown.

Comments by the department head on the fiscal impact the rule may have on businesses:

The workers' compensation system uses the same relative value (RBRVS) and coding (CPT) systems that are generally used throughout the health industry. Periodically, the RBRVS and CPT systems are updated. It is therefore necessary for the Commission to also adopt those changes and adjust its conversion factors relating to certain medical specialties in order to: 1) avoid confusion, and 2) provide adequate payment for medical care provided to injured workers. This year, the modifications to the conversion factors will result in increased payments for some medical services. These increases will very likely be factored in to workers' compensation insurance premiums but may be offset by reductions in the RBRVS values.

Jaceson R Maughan, Acting Commissioner

The full text of this rule may be inspected, during regular business hours, at the Office of Administrative Rules, or at:

Labor Commission
Industrial Accidents
HEBER M WELLS BLDG
160 E 300 S
SALT LAKE CITY, UT 84111-2316

Direct questions regarding this rule to:

• Ron Dressler at the above address, by phone at 801-530-6841, by FAX at 801-530-6804, or by Internet E-mail at [e-mail]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

11/15/2016

This rule may become effective on:

11/22/2016

Authorized by:

Jaceson Maughan, Acting Commissioner/General Counsel

RULE TEXT

R612. Labor Commission, Industrial Accidents.

R612-300. Workers' Compensation Rules - Medical Care.

R612-300-4. General Method For Computing Medical Fees.

A. Adoption of "CPT" and "RBRVS." The Labor Commission hereby adopts and by this reference incorporates:

"Optum 201[5]6 The Essential RBRVS, 201[5]6 1st Quarter Emergency Update," designated as 1761/RBRCU/U1779R--RBRC15/RBRC/U1779R, ("RBRVS" hereafter).

B. Medical fees calculated according to the RBRVS relative value unit assigned to each CPT code. Unless some other provision of these rules specifies a different method, the RBRVS is to be used in conjunction with the "conversion factors" established in subsection C. of this rule to calculate payments for medical care provided to injured workers.

C. Conversion Factors. Fees for medical care of injured workers shall be computed by determining the relative value unit ("RVU") assigned by the RBRVS to a CPT code and then multiplying that RVU by the following conversion factors for specific medical specialties:

1. Anesthesiology (1 unit per 15 minutes of anesthesia): $5[3]7.00;

2. Medicine (Evaluation and Medicine Codes 99201 - 99204 and 99211-99214): $50.00;

3. Pathology and Laboratory: $56.00;

4. Radiology: $58.00;

5. Restorative Services: $50.00;

6. Surgery (all 20000 codes, codes 49505 thru 49525, and all 60000 codes): $62.00;

7. Other Surgery: $40.00.

D. Fees for Medical care not addressed by CPT/RBRVS, or requiring unusual treatment.

1. The payor and medical provider may establish and agree to a reasonable fee for medical care of an injured worker if:

a. neither the CPT/RBRVS or any other provision of these rules address the medical care in question; or

b. application of CPT/RBRVS or other provisions of these rules would result in an inadequate fee due to extraordinary difficulty of treatment.

2. If the medical provider and payor cannot agree to a reasonable fee in such cases, the provider can request a hearing before the Commission's Adjudication Division to establish a reasonable fee.

 

KEY: workers' compensation, fees, medical practitioners

Date of Enactment or Last Substantive Amendment: [December 8, 2015]2016

Authorizing, and Implemented or Interpreted Law: 34A-1-104; 34A-2-201

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