OhioBWC - Provider - Service(Fee Schedule look-up) - Details

Fee Schedule look-up

This table contains information about the fee schedule managed care organizations (MCOs), BWC and self-insuring employers use when reimbursing for services under Ohio's workers' compensation program.

The definitions listed below apply.

Non-facility fee - The reimbursement fee for all bills with place of service codes 11 (Office), 15 (Mobile Unit), and 20 (Urgent Care Facility) for all in-state and out-of-state practitioners.

Facility fee - The reimbursement fee for all bills with place of service codes other than 11 (Office), 15 (Mobile Unit), and 20 (Urgent Care Facility) for all in-state and out-of-state practitioners.

By Report (BR) - The procedure or service is not typically covered and will not routinely be reimbursed. Many of the -BR codes are unclassified/unspecified generic codes and are currently assigned a dollar amount of $0.00. Authorization and payment of codes identified as -BR require an individual analysis by the MCO prior to submission to BWC. The MCO analysis shall include researching the appropriateness of the code in relation to the service or procedure. If the pricing is listed at $0.00, the MCO shall perform a cost comparison to determine a reasonable price. The MCO shall utilize the price to negotiate a final reimbursement rate. The provider must submit a report to the MCO for reimbursement consideration.

Prosthetics Pricing Methodology -The following three (3) prosthetic BR codes will be priced at the manufacturer's invoice price plus a negotiated percentage. This additional percentage shall not exceed a predetermined maximum based on the complexity of upper and lower extremity prosthetics. Reimbursement for all other BR prosthetic codes will continue to be established as outlined in the BR definition above. The provider must submit the manufacturer's invoice to the MCO for reimbursement consideration.
L5999 - Manufacturer invoice price plus a negotiated percentage not to exceed 35%
L8499 - Manufacturer invoice price plus a negotiated percentage not to exceed 35%
L7499 - Manufacturer invoice price plus a negotiated percentage not to exceed 50%

Not Routinely Covered (NRC) - The procedure or service is not covered unless application of the Miller criteria requires an exception. See: OAC 4123-6-16.2(B)(1) through (B)(3). Where coverage is required, the pricing is listed on the fee schedule. If the pricing is listed at $0.00, the MCO shall perform a cost comparison to determine a reasonable price. The MCO shall utilize the price to negotiate a final reimbursement rate.

Not covered (NC) - The procedure or service is never covered.

To Be Determined (TBD) - HCPCS codes noted as TBD (To Be Determined) will have pricing adopted when reimbursement rates are available from the Center for Medicare and Medicaid Services (CMS).

Negotiated - Negotiated reimbursement rates are required for designated all-inclusive per diem codes. Additionally, the MCO may need to negotiate a fee with a provider that will not accept the Ohio BWC fee schedule. In those situations, MCOs are required to attempt fee negotiation and document the provider discussion attempts. The services/supplies must be medically necessary for treatment of the work-related injury. Cost comparisons by the MCO for equitable reimbursements rates may often be necessary.

All Inclusive - All Inclusive means the service includes, but is not limited to, the examples noted for the code description.

Modifiers - BWC accepts all industry-standard modifiers as published with CPT codes by the AMA and published by CMS with HCPCS level II codes in effect on the billed date of service. The modifier code set includes 2-digit ambulance modifiers that specify trip origin and destination. Unless otherwise specified in this document, modifiers will not affect the fee schedule amount calculated for a procedure.

Modifier 22 - Unusual procedural services. Procedures with this Modifier must be individually reviewed and approved by the MCO prior to payment and must include a report documenting circumstances for its use. If use of the modifier is approved, reimbursement is 120% of fee schedule amount.

Modifier 26 - Professional component reimbursement. Payment rates vary according to the RVU assigned to the CPT code when modified.

Modifier 50 - Bilateral procedure. Reimbursement is 150% of fee schedule amount.

Modifier 52 - Reduced Services. Reimbursement is 50% of fee schedule amount.

Modifier 53 - Discontinued procedures. Reimbursement is 50% of fee schedule amount unless justification for higher specified percentage is supported by medical records documentation submitted pursuant to By Report guidelines.

Modifier 54 - Surgical care only. Reimbursement is 70% of fee schedule amount.

Modifier 55 - Post operative management only. The post operative global surgical period for major surgery is 60 days, except for postoperative visits rendered by the surgeon and treating physician following lumbar fusion surgery, pursuant to Ohio Administative Code 4123-6-32.

Modifier 56 - Pre-operative management only. Reimbursement is 10% of fee schedule amount.

Modifier 62 - Two surgeons. Reimbursement is 62.5% of fee schedule amount to each surgeon.

Modifier 80 - Assistant Surgeon Reimbursement is 20% of fee schedule amount.

Modifier 81 - Minimum Assistant Surgeon Reimbursement is 10% of fee schedule amount.

Modifier 82 - Assistant Surgeon (when qualified resident surgeon is not available). Reimbursement is 20% of fee schedule amount.

Modifier 95 - Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunication system (reimbursed at 100% of standrard fee schedule amount).

Modifier AA - Anesthesia services performed personally by anesthesiologist (required for 100% reimbursement).

Modifier AD - Medical supervision by a physician: more than four concurrent anesthesia procedures (reimbursed at 50%).

Modifier CT - Computed Tomography services furnished using equipment that does not meet each of the attributes of the national electrical manufacturers association (NEMA) XR-29-2013 standard. Reimbursement is 85% of the fee schedule amount.

Modifier FX - X-ray taken using film. Reimbursement is 80% of the fee schedule amount.

Modifier NU - New Equipment

Modifier RR - Rental equipment component reimbursement (Monthly, until purchase price is met unless an exception is noted for an individual code).

Modifier QK - Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving qualified individuals (50% of the standard fee schedule amount).

Modifier QX - Qualified non-physician anesthetist (CRNA) with medical direction by a physician is 50% of the standard fee schedule amount.

Modifier QY - Medical direction of qualified non-physician anesthetist (CRNA) by anesthesiologist is 50% of the standard fee schedule amount.

Modifier QZ - Non-physician anesthetist (CRNA) without medical direction by a physician (100% standard fee reimbursement).

Modifier TC - Technical component reimbursement. Payment rates vary according to the RVU assigned to the CPT® code when modified.


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