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:

  Optum360 Essential RBRVS 2018 annual 1st Quarter Update," (edition includes RBRC18/U1791 and U1791R2) ("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): $62.00;

  2. Medicine (Evaluation and Medicine codes 99203-99204 and 99213-99214): $56.00;

  3. Medicine (all other Evaluation and Medicine codes): $52

  4. Pathology and Laboratory: $56.00;

  5. Radiology: $58.00;

  6. Restorative Services: $50.00;

  7. Surgery (all 20000 codes, codes 49505 thru 49525, and all 60000 codes): $65.00;

  8. Other Surgery: $43.00.

  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.