| OhioBWC - Provider - Service: (Fee Schedule look-up) - Details | ||||
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| Fee Schedule look-up | |
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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. |
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| The definitions listed below apply. |
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| Non-Facility Fee - The reimbursement fee for place of service (POS) under the non-facility rate for all bills with POS codes 01,03,04,11,12,13,14,15,16,17,20,25,32,33,49,50,54,55,57,60,62,65,71,72,81 and 99.
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| Facility Fee - The reimbursement fee for POS under the facility rate for all bills with POS codes 02, 10, 19,21,22,23,24,26,31,34,41,42,51,52,53,56 and 61.
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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.
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| 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% |
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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.
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| Never Covered (NC) - The procedure or service is never covered.
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| 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)
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| 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 reimbursement rates may often be necessary.
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| All Inclusive - All Inclusive means the service includes, but is not limited to, the examples noted for the code description.
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| Non-Reimbursable Services - Non-reimbursable services are those that are designated as never covered in any BWC statute or rule or any services provided by non-covered providers not in compliance with BWC rule OAC 4123-6-25 or within the "Non-Reimbursable Services by Non-Covered Providers" definition below.
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| Non-Reimbursable Services by Non-Covered Providers - Services rendered by a provider that cannot directly enroll with BWC under OAC 4123-6-02.21 and when applicable at the time the services were rendered the rendering provider was not directly supervised by a provider who is independently licensed and BWC enrolled.
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| 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.
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| 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.
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| Modifier 26 - Professional component reimbursement. Payment rates vary according to the RVU assigned to the CPT code when modified.
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| Modifier 50 - When the procedure is bilateral eligible (indicator 1), and performed bilaterally, reimbursement is 150% of fee schedule amount.
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| Modifier 52 - Reduced services. Reimbursement is 50% of fee schedule amount. Cannot be applied to a timed therapy service code.
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| 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.
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| Modifier 54 - Intraoperative services. Reimbursement is 70% of fee schedule amount.
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| 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 Administrative Code 4123-6-32. Reimbursement is 20% of the fee schedule amount.
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| Modifier 56 - Pre-operative management only. Reimbursement is 10% of fee schedule amount.
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| Modifier 62 - Two surgeons. Reimbursement is 62.5% of fee schedule amount to each surgeon.
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| Modifier 80 - Assistant Surgeon Reimbursement is 20% of fee schedule amount.
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| Modifier 81 - Minimum Assistant Surgeon Reimbursement is 10% of fee schedule amount.
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| Modifier 82 - Assistant Surgeon (when qualified resident surgeon is not available). Reimbursement is 20% of fee schedule amount.
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| Modifier 93 - Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system. In instances when the service is eligible for audio-only telemedicine, the service code will be identified with the modifier on the Fees tab. Place of service code 10 (telehealth in home) must be reported with audio-only services.
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| Modifier 95 - Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunication system (reimbursed at 100% of standard facility column fee schedule amount). Must include POS code 02 (telehealth not in home) or POS code 10 (telehealth in home).
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| Modifier AA - Anesthesia services performed personally by anesthesiologist (required for 100% reimbursement)
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| Modifier AD - Medical supervision by a physician: more than four concurrent anesthesia procedures (reimbursed at 50%)
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| Modifier AS - Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery. Only payable when billed with modifier 80 or 81
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| 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.
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| Modifier FX - X-ray taken using film. Reimbursement is 80% of the fee schedule amount.
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| Modifier FY - X-ray taken using computed radiography technology/cassette-based imaging. Reimbursement is subject to a 7% reduction of the fee schedule amount which is applied to the technical component or the technical component of the global service.
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| Modifier GO - Always therapy modifier which must be used to identify all services delivered under an outpatient occupational therapy plan of care.
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| Modifier GP - Always therapy modifier which must be used to identify all services delivered under an outpatient physical therapy treatment plan.
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| Modifier GN - Always therapy modifier which must be used to identify all services delivered under an outpatient speech therapy treatment plan.
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| Modifier JW - Drug amount discarded/not administered to any patient. Payable in addition to the drug amount administered.
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| Modifier NU - New Equipment purchase
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| Modifier QA - Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use differ and the average of the two amounts is less than 1 liter per minute (LPM). Reimbursement is 50% of the fee schedule amount
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| Modifier QB - Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use different and the average of the two amounts exceeds 4 liters per minute (LPM) and portable oxygen is prescribed. Reimbursement is the higher of 150% of the fee schedule amount or the fee schedule amount for the portable add on. Separate monthly payment is not allowed for the portable equipment if the stationary oxygen fee schedule amount is increased by 150%.
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| Modifier QE - Prescribed amount of stationary oxygen while at rest is less than 1 liter per minute (LPM). Reimbursement is 50% of the fee schedule amount.
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| Modifier QF - Prescribed amount of stationary oxygen while at rest exceeds 4 liters per minute (LPM) and portable oxygen is prescribed. Reimbursement is the higher of 150% of the fee schedule of the fee schedule amount of the portable add-on. Separate monthly payment is not allowed for portable equipment if the stationary oxygen fee schedule amount is increased by 150%.
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| Modifier QG - Prescribed amount of stationary oxygen while at rest is greater than 4 liters per minute (LPM). Reimbursement is 150% of the fee schedule amount.
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| Modifier QR - Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use differ and the average of the two amounts is greater than 4 liters per minute (LPM). Reimbursement is 150% of the fee schedule amount
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| Modifier QK - Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals is 50% of the fee schedule amount.
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| Modifier QX - Qualified nonphysician anesthetist service: with medical direction by a physician. Reimbursement is 50% of the fee schedule amount.
*The reductions indicated below for certified nurse anesthetists (CRNAs) and anesthesiology assistants (AAs) do not apply when this modifier is billed. |
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| Modifier QY - Medical direction of one qualified non-physician anesthetist by an anesthesiologist. Reimbursement is 50% of the fee schedule amount.
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| Modifier QZ - Non-physician anesthetist (CRNA) without medical direction by a physician.
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| Modifier RR - Rental equipment component reimbursement (Monthly, until purchase price is met unless an exception is noted for an individual code).
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| Modifier TC - Technical component reimbursement. Payment rates vary according to the RVU assigned to the CPTT® code when modified.
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Modifier PC - Primary Claim (osteopathic and chiropractic treatment) reimbursement is 50% of the fee schedule amount. BWC specific modifier.
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Modifier SC - Secondary Claim (osteopathic and chiropractic treatment) reimbursement is 50% of the fee schedule amount. BWC specific modifier.
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