OWCP Medical Fee Schedule 2009
Hilda Solis, Secretary
Employment Standards Administration
Shelby Hallmark, Acting Assistant Secretary
Office of Workers' Compensation Programs
Shelby Hallmark, Director
OWCP MEDICAL FEE SCHEDULE - 2009
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 fs09_code_rvu_cf.xls
UB-04 Revenue Center Codes (RCC) that require CPT/HCPCS/OWCP
procedure codes are contained in the file named fs09rcc_req_cpt.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 fs09gpci-by-msa.xls.
A listing of geographic practice cost indices by ZIP
code is contained in the file fs09gpci-by-zip.xls
Modifier
Adjustments
Listings of Modifier Level Tables with
OWCP-designated fee schedule adjustment for each modifier are contained in the
file fs09_mod_table.xls.
* American Medical Association, Current Procedural Terminology, 2009 Edition
** Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, 2009 Edition
*** American Dental Association, Current Dental Terminology 2007-2008
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, Current Procedural
Terminology (CPT, 2009 edition).
o The
o The American Dental Association, Current Dental Terminology
2007-2008 (CDT).
o Uniform Bill 04 (UB-04, CMS-1450, OWCP-04) 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 November 19, 2008, 73 FR 224, pp.
69725-70238) 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 2009 GPCI values, OWCP has used the Geographic Practice Cost
Indices (GPCI) developed under CMS to calculate the values Medicare program
carriers use for CY 2009 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-04 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.
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-04. Some RCC codes also require appropriate
CPT/HCPCS codes. These are listed in fs09rcc_req_cpt.xls. All outpatient professional services
must be billed under the appropriate CPT/HPCS/OWCP procedure codes.
Implanted Durable Medical
Equipment & Prosthetic Implants: Most
implants are paid under the Grouper/Pricer processing of inpatient acute care
hospital bills. For outpatient
procedures, implants must be billed on a separate line using the appropriate
HCPCS code. Many implant items have maximum
fees under the OWCP fee schedule. If no
maximum allowable levels are set by the fee schedule, OWCP will pay acquisition
cost for implants, provided the bill is accompanied by a copy of the original
invoice clearly showing invoice cost less applicable discounts.
Exception – Intraocular Lenses:
For free-standing ambulatory surgical centers, intraocular lenses,
including new technology lenses, are bundled into the fee for the associated
procedure. Please include the cost of
the lens in the charge for the procedure.
It is permissible to include a line on the bill with the HCPCS code for
an intraocular lens (i.e., V2630, V2631 and V2632) and its associated cost for
information purposes only.
Acquisition Cost Policy for
Implanted Devices: Acquisition cost equals the invoice cost to
the provider, including shipping, handling and sales tax, net of all
discounts. These items must be billed
together as one charge. Wholesale
invoices for all devices must be retained in the provider’s office files for a
minimum of three years. A provider must
submit a hard copy of the invoice when an individual device or supply costs
$150.00 or more, or upon request.
Payment of a provider’s bill may be delayed if this information is not
submitted.
Prescription
Drugs: Effective
The
pharmaceutical formulary is updated periodically by First DataBank. A more detailed explanation of
the relevant drug pricing data fields, including Blue Book AWP, and how First
DataBank collects and reports such information, can be found at the First
DataBank website at http://www.firstdatabank.com. You may also contact Customer Service at
800-633-3453.
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 this URL:
http://owcp.dol.acs-inc.com/portal/main.do
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/owcp/dfec/regs/compliance/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 maxima 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, fs09mod_table.xls. 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 2009 HCPCS 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 six EXCEL® spreadsheets and
two WORD® files, and is available at the Department of Labor web
site. The URL is
http://www.dol.gov/owcp/regs/feeschedule/fee.htm
The
files contain (1) general program information; (2) information specific to
free-standing ambulatory surgical centers; (3) revenue center data and
cost-to-charge ratio data for pricing hospital outpatient and other services;
(4)a listing of valid AMA CPT, HCPCS, ADA, and OWCP program-specific codes for
CY 2009, and the relative value units (RVU) and conversion factors (CF)
assigned to each; (5) information regarding modifiers; and (6) the geographic
practice cost index (GPCI) values 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.
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-04/OWCP-04, 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 2009Ó 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-04/OWCP-04 may 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 improper reimbursement. Listing a single CPT code more than once on a
day of service may 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 appropriate units or appropriate modifier 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-04.
RCC
codes that require appropriate CPT/HCPCS codes are listed in fs09rcc_req_cpt.xls.
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 200%
of the physicians’ professional maximum for 2009. 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 payment 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 payment 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 payment 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 and implanted
devices must be submitted separately from facility fees, and bills for such
items must be accompanied by true copies of the vendor’s invoice.
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 2009 (Federal Register, Vol. 73, No. 223, pp. 68840-68933,
Addendum AA, November 28, 2008) A
complete listing of all surgical procedures which OWCP may cover in the
ambulatory surgical setting is included in file fs09asc_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 OWCP 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 OWCP population in at least a
significant number of cases. The
resulting list of procedures allows ASCs to furnish OWCP 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/owcp/dfec/regs/compliance/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 based on
prevailing reasonable and customary charges in the area where the service was
provided.. 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/owcp/owcpkeyp.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 0.70
Mal-practice expense 0.05
GPCI—
practice expense 0.942
mal-practice expense 1.724
Conversion Factor for
Radiology = $53.10
CALCULATION:
[(0.18*1.000)+(0.70*0.942)+(0.05*1.724)]
* $53.10 = $49.15
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 ccr09.xls for the table,
COST TO CHARGE RATIO HIGH VALUES FOR FY 2009 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) + 1,068.00
If LOS is greater than 60 days but less
than or equal to 90 days,
A = (MA x 1.33333) + 1,068.00 + [(LOS
- 60) x 267.00]
If LOS is greater than 90 days,
A = (MA x 1.33333) + 9,078.00 + [(LOS
- 90) x 534.00]