OWCP Medical Fee Schedule, Effective May 16, 2005
Elaine L. Chao, Secretary
Employment Standards Administration
Victoria Lipnic, Assistant Secretary
Office of Workers' Compensation Programs
Shelby Hallmark, Director
Created: April 25, 2005
OWCP MEDICAL FEE SCHEDULE – Effective May 16, 2005
PART I
INTRODUCTION
THE OWCP MEDICAL FEE SCHEDULE
PROGRAM INFORMATION
INSTRUCTIONS FOR CALCULATING THE MAXIMUM ALLOWABLE DOLLAR AMOUNT
Professional Services, Equipment, and Supplies
Inpatient Services
PART II -- DATA FILES
Procedure Codes and
CPT*, HCPCS**, CDT*** and OWCP codes, pay status codes, RVU values, conversion factors and short descriptions are contained in the file named:effective_May_16_2005_code_rvu_cf.xls
UB-92 Revenue Center Codes (RCC) that may be billed when no CPT/HCPCS codes apply are contained in the file named:
effective_May_16_2005_rcc.xls
Geographic Practice Cost Index Values
A listing of geographic practice cost indices by Metropolitan Statistical Area (MSA) names in alphabetic order is contained in the file named: effective_May_16_2005_gpci_by_msa.xls.
A listing of geographic practice cost indices by ZIP code is contained in the file named: effective_May_16_2005_gpci_by_zip.xls
* American Medical Association, Current Procedural Terminology, 2005 Edition
** Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, 2005 Edition
*** American Dental Association, Current Dental Terminology, 3rd Ed., 2000
Modifier Adjustments
Listings of Modifier Level Tables with OWCP-designated fee schedule adjustment for each modifier are contained in the file named: effective_May_16_2005_modt.xls.
NOTICE
The following coding schemes are valid for billing medical procedures, services, durable medical equipment, and supplies, under the U. S. Department of Labor's Office of Workers' Compensation Programs:
o The American Medical Association Physicians' Current Procedural Terminology (CPT, 2005 edition)
o The
o The American Dental Association, Current Dental Terminology, 3rd Edition, CDT-3/2000.
o Uniform Bill 92 (UB-92) Revenue Center Codes (for services and procedures where CPT/HCPCS or OWCP codes are not required)
o
Charges and fees for current services that are billed under codes not current on the above-listed coding schemes, or that are applicable only to state workers' compensation programs, will be denied. Such charges may be submitted again under the above-listed coding schemes.
PART I
INTRODUCTION
The U.S. Department of Labor's Office of Workers' Compensation Programs (OWCP) administers workers’ compensation programs under four federal Acts: the Federal Employees' Compensation Act (FECA), the Longshore and Harbor Workers' Compensation Act (LHWCA), the Federal Black Lung Benefits Act (FBLBA), and the Energy Employees Occupational Illness Compensation Program Act (EEOIC). The OWCP Medical Fee Schedule applies to FECA, EEOIC and LHWCA; a modified version is used for the FBLBA.
FECA (20 CFR Part 10) provides benefits for work-related injuries sustained by federal employees, employees of the U.S. Postal Service, civilian employees of the Department of Defense, members of the Peace Corps, employees of American Embassies and certain others. Under the provisions of FECA, OWCP authorizes payment for medical services and establishes limits for fees for such services (March 10, 1986, 51 FR 8276- 82, as amended; the most recent amendment was published
LHWCA (33 U.S.C. 901, et seq) provides medical benefits, compensation for lost wages, and rehabilitation services to longshoremen, harbor workers, and other maritime workers who are injured during the course of employment. By extension, various other classes of private industry workers also receive benefits. These include workers engaged in the extraction of natural resources on the outer continental shelf, employees of defense contractors’ overseas, employees at post exchanges on military bases, and others. The amendments to the regulations governing administration of the LHWCA, published October 2, 1995 60 FR 51346-348, clarify that fees by medical care providers covered by the Act shall be limited to that which prevails in the community, and that where a dispute arises, the OWCP Medical Fee Schedule shall be used to determine the prevailing reasonable and customary charge (section 702.413). Where the OWCP schedule does not establish a rate, other state or federal fee schedules, or prevailing community rates may be used. The OWCP medical fee schedule does not apply to the Jones Act.
EEOIC (20 CFR Part 30) provides compensation and medical benefits to covered employees of the United States Department of Energy (DOE), its predecessor agencies, and certain of its contractors and sub-contractors. Under the provisions of EEOIC, OWCP authorizes payment for medical services and establishes limits for fees for such services (20 CFR 30.705-713.)
THE OWCP MEDICAL FEE SCHEDULE
OWCP began to reimburse medical services under a schedule of maxima allowable amounts in 1986. Since June 1, 1994 the schedule has been based on the most recent relative value units (RVU) devised by the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) (last published January 7, 2004, 79 FR 1083-1267) for services described under the American Medical Association's Physicians' Current Procedural Terminology (CPT), and the Healthcare Current Procedure Coding System (HCPCS). In addition, the OWCP uses program-specific data and the most recent CMS Clinical Diagnostic Laboratory National Limit data, including carrier maxima, national limit, and mid-point values, to establish RVU and conversion factors for clinical laboratory procedures provided under OWCP programs. OWCP also devises its own RVU for durable medical equipment, supplies, and other items or services such as those described under procedure codes unique to the program (OWCP Codes). Such RVU are based on CMS data, state workers' compensation data, and OWCP program-specific data.
Geographic Adjustment Factors
OWCP applies geographic practice cost index values (GPCI) to each reimbursement. These values are specific to geographic locations most recently defined by the Bureau of the Census as Metropolitan Statistical Areas (MSA). For the 2005 GPCI values, OWCP has used the MSA-specific Geographic Practice Cost Indices (GPCI) developed under CMS to calculate the values Medicare program carriers use for CY 2005 carrier-designated locality adjustments.
OWCP Conversion Factors
The OWCP devises its own conversion factors (CF) for converting RVU and GPCI into maximum dollar amounts per medical service or item based on program-specific data, and national billing data from other federal programs, state workers' compensation programs and the U. S. Department of Labor's Bureau of Labor Statistics consumer price index (CPI) data.
Covered Services: The fee schedule is applicable to charges for services by medical professionals, including physicians, clinical psychologists, ophthalmologists, chiropractors, osteopaths, podiatrists, physicians' assistants, therapists, and medical technologists/ technicians. OWCP also applies a schedule to certain durable medical equipment, supplies and other items or services covered under the program.
Inpatient Services: Effective
Hospital-based inpatient services should be billed on the UB-92 showing revenue center charges, ICD diagnostic and procedure codes and the hospital's Medicare number. Inaccurate coding may cause inappropriate reimbursement, erroneous reductions in allowable amounts and/or delays in bill processing. The physician's professional services should be coded and billed on Form CMS-1500/OWCP-1500 (formerly HCFA-1500/OWCP-1500).
Outpatient Services: Ancillary charges for hospital outpatient services (emergency room, recovery room, operating room) should be billed under the appropriate Revenue Center Code (RCC) on the UB-92. All outpatient professional services must be billed under the appropriate CPT/HPCS/OWCP procedure codes.
Prescription Drugs: Effective
The pharmaceutical formulary is updated each month by the Red Book Update. For information on the Red Book or the Red Book Update, contact the Red Book publishers:
Thomson Medical Economics
Phone: 201-358-7200
Internet: www.pdrbookstore.com
e-mail: pdrbookstore@medec.com
Prescription drugs should be billed under the correct NDC on the Uniform Claim Form either in hard copy or electronic format; show the trade or generic name, and the quantity provided.
Requests to determine if a drug is payable under a particular claim should be directed to our Medical Authorizations Unit at (866) 335-8319. Callers must have the NDC number of the drug in order to receive a prior authorization. Eligibility may also be checked via the web at http://owcp.dol.acs-inc.com. You must have the Case Number, NDC code and the date the prescription was (or is to be) filled.
Effective
Further information on electronic billings may be found at the OWCP web site: http://www.dol.gov/esa/regs/compliance/owcp/CBPOutreach.htm
Other Services: OWCP will continue to exercise its current authority to establish maxima for certain services, items of durable medical equipment, facility use fees, and other charges not currently on the schedule. Providers will be notified of major schedule changes. All fees without an OWCP-established maximum are subject to review based on prevailing reasonable and customary charges in the area where the service was provided.
Procedure Coding:
Non-physician Providers: NON-PHYSICIAN HEALTH CARE PROFESSIONALS MUST USE THE APPROPRIATE HCPCS MODIFIERS TO IDENTIFY THEIR CREDENTIALS WHEN USING CODES ALSO USED BY PHYSICIANS (MD/DO) AS DEFINED UNDER THE ACT. Modifiers acceptable to OWCP are listed on the Modifier Level Table in this publication. Non-physician providers, who are required to use modifiers, but do not, may not be reimbursed until services are correctly billed.
Home Health Services: Home health services should be billed under the appropriate HCPCS 2005 codes or OWCP program-specific codes.
Charges in Excess of the Maxima allowable: By regulation [20 C.F.R. 10.813], a provider is to charge OWCP their lowest fee charged to the general public. The OWCP fee schedule is not be used to establish billing rates. A provider, whose fee for services is partially paid by OWCP as a result of the application of the schedule of maxima allowable charges, shall not request reimbursement from the injured employee (patient) for any amount in excess of the maximum allowable. A provider who collects or attempts to collect any amount in excess of the maximum allowable fee may be subject to exclusion from payment under the Federal Employees' Compensation Act. Such exclusion of a provider will be reported by OWCP to all Federal employing agencies, the Centers for Medicare and Medicaid Services, and the state or local authority responsible for licensing or certifying the excluded provider.
Appeals:
Provider: A provider whose charge for service is partially paid because it exceeds the maximum allowable amount may, within 30 days of payment, request reconsideration of the fee determination. Such request should be made to the OWCP District Office having jurisdiction over the injured employee's (patient's) case, and must be accompanied by documentary evidence that (1) the actual procedure performed was incorrectly identified by the original code, or (2) the presence of a severe or concomitant medical condition made treatment especially difficult, or (3) the provider possessed unusual qualification (Board Certification in a specialty is not sufficient evidence in itself of unusual qualifications). These are the only circumstances which will justify reevaluation of the amount paid. If the OWCP district office issues a decision which continues to disallow a contested amount, the provider may apply to the Regional Director of the region with jurisdiction over the OWCP district office. The application must be filed within 30 days of the date of such decision, and it may be accompanied by additional evidence.
Reimbursed Employee (patient): If an employee is partially reimbursed for medical expenses because the amount he or she paid to the medical provider exceeds the maximum allowable, the employee may take the following actions in the order presented: (1) request the provider to refund or credit the difference, (2) request the provider to submit at no additional cost a request for reconsideration of the fee determination as described above, (3) request the OWCP District Office with jurisdiction to contact the provider concerning the amount paid in excess of the allowable maximum.
OWCP FEE SCHEDULE PUBLIC USE FILES
Publications: The OWCP medical fee schedule is published in electronic format only in the form of nine EXCEL® spreadsheets and two WORD® files, and is available at the Department of Labor web site. The URL is
http://www.dol.gov/esa/regs/feeschedule/fee.htm.
The files contain (1) general program information; (2) a listing of valid AMA CPT, HCPCS, ADA, and OWCP program-specific codes for CY 2005, and the relative value units (RVU) assigned to each; and (3) the geographic practice cost index factors (GPCI) for each metropolitan statistical area (MSA), or state rural area in (a) alphabetic order by the primary name of the MSA, and (b) by ZIP code in ZIP code order. To locate cities or towns not specified in the name of the MSA, search by ZIP code. Counties included in a designated MSA are assigned GPCI values for that MSA. Counties assigned to an MSA are identified on the State and County list by MSA number in the MSA column (MSA/PMSA/NECMA).
Common Billing Information
Billing Forms: Unless otherwise instructed, all charges should be presented on standard forms - the CMS-1500/OWCP-1500 (formerly HCFA-1500/OWCP-1500) or the UB-92, and submitted to the U.S. Department of Labor, Office of Workers' Compensation Programs, Division of Federal Employees' Compensation at the following address:
DFEC Central Mailroom
Employee Identification: The injured employee's social security number must be listed on each bill; the OWCP/DFEC claim number must be listed as well when available. Complete identification will speed processing.
Procedure Coding: For billing purposes, all physician services, regardless of setting, and all outpatient professional services, including the technical components of radiology, pathology, and clinical laboratory must be recorded using CPT/HCPCS codes or those provided by the OWCP.
Coding conventions as described in the CPT 2005 should be carefully observed, including the use of modifiers. Incorrect coding or the failure to indicate the correct number of units (frequency) on the CMS-1500/OWCP-1500 or UB-92 will result in inappropriate reimbursement. In addition, OWCP reviews services billed under CPT codes for coherence with the AMA's description of the procedure, and other common standards for appropriateness of use. When a procedure has been prior-authorized by OWCP, consult the authorizer if there is any question concerning the correct coding, especially for comprehensive functional capacity evaluations, occupational rehabilitation programs (work hardening/work conditioning), and pain management programs. Non-specific CPT/HCPCS codes ending in "99" are usually considered inappropriate coding, and frequently result in inadequate reimbursement. Listing the same CPT code more than once on a day of service will result in denial of all but one of the charges because it will be interpreted by the OWCP automated system as duplicate charges; if a procedure covered under a singular CPT/HCPCS code was provided more than once on the same day, use units to indicate frequency. Non-standard coding and incomplete information will result in delayed and/or erroneous reimbursements.
For hospital outpatient facilities: facility charges should be identified by Revenue Center Codes (RCC) on the UB-92.
22X Special Charges; charges incurred on a daily basis for certain services.
All Subcategories
23X Incremental Nursing Charge Rate; charge for nursing service in addition to room and board
230 General Classification
239 Other
Note: that no other subcategory could apply to outpatient surgery.
24X All Inclusive Ancillary; a flat rate charge for ancillary services only.
240 General Classification
249 Other Inclusive Ancillary
25X Pharmacy; charges for medications, including blood plasma, other components of blood, and IV solutions.
250 General Classification
251 Generic Drugs
252 Non-generic Drugs
253 Take Home Drugs
254 Drugs Incident to Other Diagnostic Services (if incident to the limited diagnostic services, including simple pre-operative laboratory tests usually included in ASC facility fee.)
255 Drugs Incident to Radiology (if the radiology procedure is used to guide the surgeon in performance of the primary surgical procedure.)
257 Non-prescription
258 IV Solutions
259 Other Pharmacy
Note: Subcategory 256 – Experimental Drugs is not included in the facility fee.
27X Medical/Surgical Supplies and Devices
270 General Classification
271 Non-Sterile Supply
272 Sterile Supply
273 Take Home Supplies
276 Intraocular Lens
279 Other Supplies/Devices
Note: These Subcategories are not included in the facility fee:
274 – Prosthetic Devices
275 – Pacemaker
276 – Oxygen, Take Home
278 – Other Implants
30X Laboratory
300 General Classification
305 Hematology
307 Urology
Note: These Subcategories are not included in the facility fee:
301 – Chemistry
302 – Immunology
303 – Renal Patient (Home)
304 – Non-routine Dialysis
306 – Bacteriology & Microbiology
309 – Other Laboratory
36X Operating Room Services
360 General Classification
361 Minor Surgery
369 Other Operating Room Services
37X Anesthesia
370 General Classification
379 Other Anesthesia
38X Blood
380 General Classification
381 Packed Red Cells
382 Whole Blood
383 Plasma
384 Platelets
385 Leucocytes
386 Other Components
387 Other Derivatives
389 Other Blood
39X Blood Storage and Processing
390 General Classification
391 Blood Administration
399 Other Blood Storage & Processing
49X Ambulatory Surgical Care
490 General Classification
499 Other Ambulatory Surgical Care
70X Cast Room
700 General Classification
709 Other Cast Room
71X Recovery Room
710 General Classification
719 Other Recovery Room
76X Treatment or Observation Room
760 General Classification
769 Other Treatment
Facility fees for services provided by freestanding ambulatory surgery centers under the OWCP medical fee schedule
State waiver: Ambulatory surgery services provided in a hospital-based ambulatory surgical center in
Facility fees: Facility fees associated with procedures performed in freestanding ambulatory surgical centers are paid according to calculations based on the CPT code for the surgical procedure(s) performed. Bills are to be submitted on the Form HCFA/OWCP–1500. Each surgical procedure is to be indicated by the appropriate CPT Code with the OWCP modifier SG appended to indicate that the facility fee is being charged. The SG modifier carries a multiplier of 175% of the physicians’ professional maximum for 2005. Payment rates are also adjusted for the performance of multiple surgical procedures. The adjustment criteria calculates payment allowing 100% of the maximum allowable charge for the highest priced procedure and 50% of the maximum allowable charge on secondary, tertiary and all other procedures. Actual payment is based on the calculated payment rate or the billed charge, whichever is less.
These payment rates established under the OWCP medical fee schedule only apply to facility charges. The rate does not include physician fees, anesthesiologist fees, or fees of other professional providers authorized to render ambulatory surgery procedures and to bill independently for them. Professional fees must be submitted separately from facility fees. The rate does not apply to laboratory, x-rays or diagnostic procedures other than those directly related to the surgical procedure. Charges for non-surgical diagnostic services must be submitted separately from facility fees. The rate does not apply to surgically implanted prosthetic devices; ambulance services; leg, arm, and back braces; artificial limbs; or durable medical equipment for use in the patient’s home. Charges for DME/POS must be submitted separately from facility fees.
Note: a radiology/diagnostic procedure is considered to be directly related to the performance of the surgical procedure only if it is an inherent part of the surgical procedure, e.g., the CPT code for the surgical procedure includes the diagnostic or radiology procedure as part of the code description. Radiology/diagnostic procedures performed prior to the date of ambulatory surgery are processed separately and are paid under the appropriate sections of the OWCP medical fee schedule.
Covered ASC Facility Services include:
• Nursing services, services of technical personnel, and other related services;
• Use of the ASC facilities by the patient;
• Drugs, including take-home medications, biologicals, surgical dressings, supplies, splints, casts, appliances and equipment directly related to the surgical procedure;
• Diagnostic or therapeutic items and services directly related to the surgical procedure (including simple preoperative laboratory tests, e.g., urinalysis, blood hemoglobin or hematocrit);
• Administrative, record keeping and housekeeping items and services;
• Blood, blood plasma, platelets, etc.
• Materials for anesthesia; and
• Intraocular lenses (IOLs).
ASC Approved Procedures include most CPT codes approved by the Medicare program for its ASC list for 2005 (Federal Register, Vol. 68, No. 60, pp. 15267—15312, March 28, 2003, as amended by Attachment A to DHHS/CMS Program Memorandum AB 02-137.) A complete listing of all surgical procedures which OWCP may cover in the ambulatory surgical setting is included in the file effective_May_16_2005_asc_pymt_grp.xls.
This list does not include procedures that are currently performed on an ambulatory basis in a physician’s office and that do not generally require the more elaborate facilities of an ASC. Neither does the list include procedures that are appropriately performed in an inpatient hospital setting or an outpatient hospital setting, but would not be safely performed in an ASC. We recognize that there are some procedures that might be appropriately performed in ASC for the younger patient who is generally healthy. But for the larger number of FECA beneficiaries whose health is more likely to be compromised by disability and age, an ASC may be a questionable setting for those same procedures. Therefore, we are including in the list only those procedures that can be safely performed in an ASC on the general FECA population in at least a significant number of cases. The resulting list of procedures allows ASCs to furnish FECA beneficiaries with a broad range of surgical services that reflect the practice of contemporary surgery without compromising patient safety.
OWCP Program Requirements for Prior Authorization: Elective surgery, therapeutic services provided beyond customary time periods (e.g. prolonged physical therapy treatments or therapy initiated long after the injury), and comprehensive rehabilitation services such as work hardening/work conditioning programs, or pain management programs, must be prior-authorized. All Medical Authorizations are now handled by our private contractor, ACS. The voice phone number for medical authorizations is (866) 335-8319, Monday-Friday,
Further information, including specific information to include in requests for authorization, and our online tool for Eligibility, Authorization and Bill Payment can be obtained at the DOL web site: http://www.dol.gov/esa/regs/compliance/owcp/CBPOutreach.htm
Reimbursement Rates: Invoices are processed through an automated system, and are reimbursed at the billed amounts unless a particular charge exceeds the maximum allowable; such charges are reimbursed at the maximum allowable amount under the OWCP medical fee schedule. Procedures without an assigned maximum allowable (no RVU values have been assigned) are reviewed independently. To determine the maximum allowable amount for a particular procedure, see the instructions on page 17, below.
PROGRAM INFORMATION
For additional information concerning the OWCP schedule of maximum allowable amounts, or codes for OWCP-ordered services such as occupational rehabilitation, functional capacity evaluations, or pain management programs, contact the nearest OWCP District Office. Current addresses and phone numbers may be obtained at the DOL web site:
http://www.dol.gov/esa/contacts/owcp/fecacont.htm
National Office Contact:
U. S. Department of Labor
Office of Workers' Compensation Programs
Division of Planning, Policy and Standards
Room S-3524
Telephone: (202) 693-0035
Facsimile: (202) 693-1378
INSTRUCTIONS FOR CALCULATING THE MAXIMUM ALLOWABLE DOLLAR AMOUNT
PER PROCEDURE FOR A SPECIFIC AREA
Each procedure subject to a maximum allowable amount (MAA) under the OWCP medical fee schedule has been assigned three relative values: work (W), practice expense (PE), and mal-practice expense (MP). Each of these three values are multiplied by three related values for geographic variance in procedure costs called geographic practice cost index values (GPCI): work (w), practice expense (pe), and mal-practice expense (mp). The resultant value is multiplied by a conversion factor (CF) to convert it into a dollar amount.
The Formula is:
[(Wrvu * wgpci) + (PErvu * pegpci) + (MPrvu * mpgpci)] * CF = MAA
Where: Wrvu = Work relative value units
wgpci = Work geographic practice cost index value
PErvu = Practice expense relative value units
pegpci = Practice expense geographic practice cost index value
MPrvu = Mal-practice relative value units
mpgpci = Mal-practice geographic practice cost index value
EXAMPLE: CPT 73562: Radiological examination, knee; minimum of three views, hospital setting.
Place of Service:
CPT 73562 RVU: Work 0.18
Practice expense 0.63
Mal-practice expense 0.05
GPCI—
practice expense 0.940
mal-practice expense 1.272
Conversion Factor for Radiology = $50.58
CALCULATION:
[(0.18*1.00000) + (0.63*0.940) + (0.05*1.272] * $50.58 = $42.27
OWCP INPATIENT BILL PROCESSING FORMULAE
Inpatient bills are currently processed under three categories:
1. Hospital Services exempt from the CMS Prospective Pay System (PPS).
OWCP applies a "cost-to-charge" (CCR) ratio formula that is based on CMS's case-weighted data for hospital operating and capital costs per state. All PPS-exempt hospitals in a state are paid at the same ratio.
((
See the file named ccr05 for the table, COST TO CHARGE RATIO HIGH VALUES FOR FY 2005 FOR CALCULATING MAXIMUM ALLOWABLES FOR NON-PPS HOSPITAL SERVICES
2.
3. Hospital services covered under the CMS Prospective Pay System (PPS) are paid under the following formula based on:
A = OWCP maximum allowable payment;
LOS = The claimant's length of stay; and
MA = CMS Medicare allowable amount calculated using the versions of Grouper and Pricer software appropriate to the discharge date.
If LOS is less than or equal to 60 days,
A = (MA x 1.33333) + 912.00
If LOS is greater than 60 days but less than or equal to 90 days,
A = (MA x 1.33333) + 912.00 + [(LOS - 60) x 228.00]
If LOS is greater than 90 days,
A = (MA x 1.33333) + 7,752.00 + [(LOS - 90) x 456.00]