DAR File No. 28729

Labor Commission, Industrial Accidents

R612-2-5

Regulation of Medical Practitioner Fees

NOTICE OF PROPOSED RULE

DAR File No.: 28729
Filed: 05/15/2006, 10:11
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of the proposed rule change is to update references to the 2006 edition of the National Centers for Medicare and Medicaid Services (CMS) for the Medicare Physician Fee Schedule (MPFS) Resource-Based Relative Value Scale (RBRVS) and the 2006 edition of the American Medial Association's CPT-4 coding guidelines. The proposed rule change also makes some clerical corrections.

Summary of the rule or change:

The proposed amendment adopts and incorporates the 2006 edition of the National Centers for Medicare and Medicaid Services' RBRVS, as well as the 2006 edition of the American Medical Association's CPT-4 coding guidelines. The updated RBRVS and CPT-4 clarify provisions for payment of SSEP monitoring and chiropractic treatment provided by physical therapists. The amendment also makes some nonsubstantive clerical corrections.

State statutory or constitutional authorization for this rule:

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

National Centers for Medicare and Medicaid Services (CMS) for the Medicare Physician Fee Schedule (MPFS) Resource-Based Relative Value Scale 2006 edition; and the American Medical Association's CPT-4 2006 edition coding guidelines

Anticipated cost or savings to:

the state budget:

There will be no aggregate cost or savings to the State budget. The amendment will impose no new costs of enforcement or administration on the Labor Commission. With respect to the State's expense in its capacity as an employer of injured workers, the proposed changes are of minor impact and will produce no overall savings or costs.

local governments:

There will be no aggregate cost or savings to local governments. In local government's capacity as employers of injured workers, the proposed changes are of minor impact and will produce no overall savings or costs.

other persons:

There will be no aggregate cost or savings to other persons. The proposed changes are of minor impact and will produce no overall savings or costs to the employers, insurance carriers, or medical providers that are subject to the changes.

Compliance costs for affected persons:

The proposed amendment reflects a minor refinement and updating of existing standards. On balance, the amendments are fiscally neutral and will impose no additional compliance costs on affected persons.

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

The proposed amendment will have no fiscal impact on business. Businesses are currently subject to the requirement of previous versions of the RBRVS and CPT-4. The proposed amendment reflects a minor refinement and updating of existing standards, but with no overall additional cost. R. Lee Ellertson, Commissioner

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

Direct questions regarding this rule to:

Joyce Sewell at the above address, by phone at 801-530-6988, by FAX at 801-530-6804, or by Internet E-mail at jsewell@utah.gov

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:

07/03/2006

This rule may become effective on:

07/11/2006

Authorized by:

R Lee Ellertson, 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[5]6 edition, as the method for calculating reimbursement and the American Medical Association's CPT-4, 200[5]6 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]11, 200[5]6: (Conversion Rates below EFFECTIVE July 11, 2006, 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;

Pathology and Laboratory 150% of Utah's published Medicare carrier;

Radiology $53.00;

Restorative [Medicine]Services $44.00, 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]11, 200[5]6. 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.

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: [July 2, 2005]2006

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

ADDITIONAL INFORMATION

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For questions regarding the content or application of this rule, please contact Joyce Sewell at the above address, by phone at 801-530-6988, by FAX at 801-530-6804, or by Internet E-mail at jsewell@utah.gov

For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.