No. 31333 (Amendment): R612-2-5. Regulation of Medical Practitioner Fees

DAR File No.: 31333
Filed: 04/30/2008, 01:15
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this amendment is to adopt, with modifications, the 2008 Resource-Based Relative Value Schedule (RBRVS) and the 2008 American Medical Association Current Procedural Terminology (CPT) coding standards.

Summary of the rule or change:

The proposed amendment updates the existing rule by incorporating the 2008 versions of the RBRVS and CPT. The amendment also assigns a relative value of $46 for the evaluation and management of medical care provided to injured workers.

State statutory or constitutional authorization for this rule:

Sections 34A-2-101 et seq., 34A-3-101 et seq., and 34A-1-104

This rule or change incorporates by reference the following material:

National Centers for Medicare and Medicaid Service (CMS) for the Medicare Physician Fee Schedule (MPF)"Resource-Based Relative Value Scale" (RBRVS) 2008 edition; and the American Medical Association's CPT, 2008 edition coding guidelines

Anticipated cost or savings to:

the state budget:

The proposed amendment will impose no additional administrative or enforcement costs on the state budget. The minimal increase in workers' compensation medical expense that will result from this amendment is unlikely to affect workers' compensation premiums. Consequently, the amendment will not result in any measurable increase in the state's cost of workers' compensation insurance.

local governments:

The minimal increase in workers' compensation medical expense that will result from this amendment is unlikely to affect workers' compensation premiums. Consequently, the amendment will not result in any measurable increase in local governments' cost of workers' compensation insurance.

small businesses and persons other than businesses:

The minimal increase in workers' compensation medical expense that will result from this amendment is unlikely to affect workers' compensation premiums. Consequently, the amendment will not result in any measurable increase in the cost of workers' compensation insurance for small businesses or other persons.

Compliance costs for affected persons:

Currently workers' compensation benefits cost Utah employers and insurance carriers approximately $200,000,000 per year. The proposed amendment will increase these costs by $225,000 or approximately one-tenth of one percent.

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

The minimal increase to workers' compensation medical costs provided by this rule are relatively insignificant and unlikely to have any fiscal impact on the businesses subject to the rule. Sherrie Hayashi, Commissioner

The full text of this rule may be inspected, during regular business hours, at the Division 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:

Larry Bunkall at the above address, by phone at 801-530-6988, by FAX at 801-530-6844, 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:

06/16/2008

This rule may become effective on:

06/23/2008

Authorized by:

Sherrie Hayashi, Commissioner

RULE TEXT

R612. Labor Commission, Industrial Accidents.

R612-2. Workers' Compensation Rules-Health Care Providers.

R612-2-5. Regulation of Medical Practitioner Fees.

Pursuant to Section 34A-2-407:

A. The Labor Commission of Utah:

1. Establishes and regulates fees and other charges for medical, surgical, nursing, physical and occupational therapy, mental health, chiropractic, naturopathic, and osteopathic services, or any other area of the healing arts as required for the treatment of a work-related injury or illness.

2. Adopts and by this reference incorporates the National Centers for Medicare and Medicaid Services (CMS) for the Medicare Physician Fee Schedule (MPFS) "Resource-Based Relative Value Scale" (RBRVS), 200[7]8 edition, as the method for calculating reimbursement and the American Medical Association's CPT-4, 200[7]8 edition, coding guidelines. The non-facility total unit value will apply in calculating the reimbursement, except that procedures provided in a facility setting shall be reimbursed at the facility total unit value and the facility may bill a separate facility charge. The CPT-4 coding guidelines and RBRVS are subject to the Utah Labor Commission's Medical Fee Guidelines and Codes and the following Labor Commission conversion factors for medical care rendered for a work-related injury or illness, effective July 1[1], 200[7]8: (Conversion Rates below EFFECTIVE July 1[1], 200[7]8, to be used with the RBRVS procedural Unit value as per specialty.)

Anesthesiology $41.00 (1 unit per 15 minutes of anesthesia);

[Medicine E and M $44.00;

]Evaluation and Management [Codes 99201-99204 and 99211-99214 $45]$46.00

Pathology and Laboratory [150% of Utah's published Medicare carrier]The current RBRVS identifies values for specific codes that require Pathologist services. All other reimbursement rates for laboratory and pathology codes will be determined by the Ingenix ga-filled methodology. $52.00;

Radiology $53.00;

Restorative Services $4[4]6.00, with Utah code 97001 and 97003 at a 1.5 relative value unit and Utah code 97002 and 97004 at a 1.0 of relative value unit.

Surgery $37.00;

All 20000 codes, codes 49505 thru 49525 and all 60000 codes of the CPT-4 coding guidelines $58.00.

3. Adopts and incorporates by this reference the Utah Labor Commission's Medical Fee Guidelines and Codes, as of July 1[1], 200[7]8. The Utah Medical Fee Guidelines and Codes can be obtained from the division for a fee sufficient to recover costs of development, printing, and mailing or can be downloaded at the Labor Commission's website at [www.laborcommission.utah.gov/indacc/indacc.htm]http://laborcommission.utah.gov/IndustrialAccidents/pdfs/Med%20Fee%20Guidelines%20%202007%2008-07.pdf.

4. Decides appropriate billing procedure codes when disputes arise between the medical practitioner and the employer or its insurance carrier. In no instance will the medical practitioner bill both the employer and the insurance carrier.

B. Employees cannot be billed for treatment of their work-related injuries or illnesses.

C. Discounting from the fees established by the Labor Commission is allowed only through specific contracts between a medical provider and a payor for treatment of work-related injury or illness.

D. Restocking fee 15%. Rule R612-2-16 covers the restocking fee.

E. Dental fees are not published. Rule R612-2-18 covers dental injuries.

F. Ambulance fees are not published. Rule R612-2-19 covers ambulance charges.

 

KEY: workers' compensation, fees, medical practitioner

Date of Enactment or Last Substantive Amendment: [October 9, 2007]2008

Notice of Continuation: May 28, 2003

Authorizing, and Implemented or Interpreted Law: 34A-2-101 et seq.; 34A-3-101 et seq.; 34A-1-104