Fee Schedules

Effective July 1, 2011.

This site contains the policies, payment methods, billing codes, and maximum fees used to pay health care and vocational providers who treat injured workers.

Make sure to check the Updates & Corrections tab for any changes to the Fee schedules. Read about the highlights of changes in the last year. These changes are also included in the payment policies.

2011 Quick Reference Fee Schedule

Professional and Facility Services Fee Schedules (July 2011)
Item		Excel
Professional Services Fee Schedule – Excel spreadsheet of the complete fee schedule excluding the ASC Fees, AP-DRGs, Hospital Rates and Residential Facility Rates.		5,231 KB
Item	PDF
Anesthesia - CPT ™ 00100 - 01999	141 KB
Evaluation and Management - CPT ™ 99201 - 99499	180 KB
Surgery - CPT ™ 10021 - 69990	1,592 KB
Radiology - CPT ™ 70010 - 79999	777 KB
Pathology and Laboratory - CPT ™ 80047 - 89356	504 KB
Medicine - CPT ™ 90281 - 99607	541 KB
CPT ™ Category II and III - CPT ™ 0001F - 0192T	262 KB
HCPCS - HCPCS A0021 - V5364	1,788 KB
Medical and Surgical Supplies Codes - HCPCS A4206-A9999 (For DME Providers)	158 KB
Hospital Only Codes - C1300 - S0093	239 KB
Local Codes by Code - 0401A - 5093V, R0310 - R0392, & V0028	121 KB
Local Codes by Specialty - 0401A - 5093V, R0310 - R0392, & V0028	204 KB
ASC Fee Schedules - All approved codes	442 KB
AP-DRG Assignment - Version 23	112 KB
Hospital Rates	100 KB
Residential Facility Rates	58 KB

Fee Schedules - Comma delimited version		Field Key
Complete fee schedule excluding the ASC Fees, AP-DRGs, Hospital Rates and Residential Facility Rates.	1,512 KB	10 KB
Anesthesia	7 KB	7 KB
Ambulatory Surgery Center	177 KB	66 KB
AP-DRG	48 KB	38 KB
Hospital	13 KB	41 KB

Billing & Payment Policies

Effective July 1, 2011

(Republished February 1, 2012)

Return to Fee Schedule Lookup

These billing and payment policies determine under what conditions we will pay health care and vocational providers who treat injured workers and crime victims.

Note: Make sure to check the Updates & Corrections tab for any changes to the Payment policies.

Payment Policies - Complete (2.80 MB PDF)
Chapter #	Title
1	Introduction
2	Information for All Providers
Professional Services
3	Ambulance Services
4	Anesthesia Services
5	Audiology and Hearing Services
6	Biofeedback, Electrodcardiograms (EKG), Electrodiagnostic services, and Extracorporeal shockwave therapy (ESWT)
7	Chiropractic Services
8	Dental Services
9	Durable Medical Equipment (DME)
10	Evaluation and Management (E/M) Services
11	Home Health Services
12	Impairment Rating Services
13	Independent Medical Exams (IME)
14	Interpretive Services
15	Medical Testimony
16	Medication Administration
17	Modifications: Home, Job, and Vehicle
18	Naturopathic Physicians
19	Nurse Case Management
20	Obesity Treatment
21	Other Services
22	Pathology and Laboratory Services
23	Pharmacy Services
24	Physical Medicine Services
25	Psychiatric Services
26	Radiology Services
27	Reports and Forms
28	Supplies, Materials, and Bundled Services
29	Surgery Services
30	Vocational Services
31	Washington RBRVS Payment System
Facility Services
32	Ambulatory Surgery Centers (ASCs)
33	Brain Injury Rehabilitation Services
34	Chronic Pain Management
35	Hospitals
36	Nursing Home and Other Residential Care Services
Appendices
A	Bundled Services
B	Bundled Supplies
C	Documentation requirements
D	Endoscopy families
E	Modifiers that affect payment
F	Noncovered codes and modifiers
G	Outpatient drug formulary

 

Highlights of Changes

This Medical Aid Rules and Fee Schedules (fee schedule) is effective for services provided on or after July 1, 2011. These highlights are intended for general reference; they are not a comprehensive list of all the changes in the fee schedule. Refer to the 2011 CPT© and HCPCS coding books for complete code descriptions and lists of new, deleted or revised codes.

Washington Administrative Code (WAC) and payment changes

• Cost of living adjustments were not applied to RBRVS and anesthesia services or to most local codes.
• WAC 296-20-135 reduces the RBRVS conversion factor to $55.34 while the anesthesia conversion factor remains at $3.19 per minute ($47.85 per 15 minutes).
• WAC 296-23-220 and WAC 296-23-230 maintain the maximum daily cap for physical and occupational therapy services at $118.07
• WAC 296 -23 -250 set a daily cap for massage therapy of 75% of the daily cap for PT/OT services. The rate for July will remain $88.55.

Policy & fee schedule additions, changes and clarifications

Introduction

• Added a new section addressing self-insurers.

Professional Services

• Updated the telephone call policy to cover detailed messages.
• Revised the list of injection codes that now include diagnostic imaging in the description.
• Revised the examples for billing physical therapy services.
• Expanded the work conditioning policy.
• Added a new policy on drug screens.
• Outlined coverage for buprenorphine and buprenorphine/naloxone.
• Independent Medical Exam section includes new codes for no shows for neuropsychological testing and PCEs scheduled by the department.
• Interpretive services section reflects new telephone interpreter services.

Facility Services

• Fees including Hospital AP-DRG and Per Diem rates have been updated.

Appendices

• Preferred Drug List has been updated.
• Other appendices have been updated with new codes.

Fee Schedules

• With the exception of the comma delimited files, the Field Keys are integrated into the fee schedules.
• A new fee schedule for medical and surgical supplies has been established for suppliers who routinely bill for these items. Items listed in the Professional Fee Schedule as bundled will remain bundled for other providers.
• The following fee schedules have been updated:
• Professional fees.
• Durable medical equipment fees.
• Prosthetics and Orthotics fees.
• Laboratory fees.
• Pharmacy fees.
• Dental fees.
• Interpreter fees.
• Hospital AP-DRG outlier thresholds.
• Hospital percent of allowed charge (POAC) factors.
• Hospital rates.
• Hospital ambulatory payment classification (APC) rates.
• Residential fees.
• Ambulatory surgery center (ASC) fees.

Unless noted, all policies in the Medical Aid Rules and Fee Schedules apply to claimants receiving benefits from either the State Fund, the Crime Victims Compensation Program or Self-Insurers.

Providers must follow the administrative rules, medical coverage decisions and payment policies applicable to L&I. You can find this information in the Medical Aid Rules and Fee Schedules, Provider Bulletins and Provider Updates.

Updates & Corrections

On this page view:

• Updates to payment policies or fee schedules.
• Corrections to payment policies or fee schedules.

Updates

Payment policy updates

Payment policy updates
Posting date	Policy Area	Description
April 25, 2012	Hospitals	APR-DRG System Replacing AP-DRG System The Department of Labor & Industries is planning to change its current DRG payment method based on All Patient Diagnostic Related Groups (AP-DRGs) to an All Patient Refined Diagnostic Related Groups (APR-DRGs) system. Implementation is currently scheduled for October 1, 2012.
March 27, 2012	Hospitals	Swedish Hospital Issaquah has become an Acute Care Hospital provider for Labor and Industries. Effective dates for service beginning February 2012.
February 1, 2012	Hospitals	Out of country Hospitals - Paid by an out of country POAC factor. Effective February 1, 2012 the rate is 100%.
December 6, 2011	Pathology and Laboratory Payment Policies	Correction to payment limits for Pathology and Laboratory Payment Policies. The correct payment limits for the drug screen codes are: Payment Limits 80100, 80102 and G0431 are only payable to laboratories that don't require a CLIA certificate of waiver. G0434 is limited to one unit per day per patient encounter regardless of the CLIA status of the laboratory.
November 23, 2011	Surgery Services	Effective December 1, 2011, L&I will not cover the following codes based on a decision of the Health Technology Clinical Committee: 29914, Hip arthroscopy with femoroplasty. 29915, Hip arthroscopy with acetabuloplasty. For more information, see the committee's decision at http://www.hta.hca.wa.gov/documents/findings_decision_fai.pdf
November 8, 2011	Reports and Forms	Report of Industrial Injury or Occupational Disease (State Fund) Payment policy update Effective January 1, 2012 a new web incentive will be available for ROAs submitted electronically. The full payment policy is available here.
October 24, 2011	Nursing Homes	Billing code change for the Nursing Home Fee Schedule. Group #9, Clinically Complex, will bill 8887H effective November 1, 2011 Adjustment Notice
August 19, 2011	Surgery Services	Example 4 in the Endoscopy Payment Policies section is incorrect. This is the corrected example: Endoscopy Example 4
August 18, 2011	Medication Administration	The fees for the hyaluronic acid injections were inadvertently not updated in the payment policies section. The following table contains the correct fees. HCPCS Code Description Maximum Fee J7321 Hyalgan or Supartz inj $140.40 J7323 Euflexxa, inj $203.81 J7324 Orthovisc, inj $270.00 J7325 Synvisc or Synvisc-1, per mg $ 17.98
June 1, 2011	Reports and Forms	New payment policy for Report of Accident and Provider's Initial Report (billing code 1040M). Research shows that when work related conditions or injuries are reported promptly, worker outcomes improve. Effective July 1, 2011, to encourage prompt reporting, the insurer will pay for the Report of Accident or Provider's Initial Report (billing code 1040M) on a graduated scale based on when the insurer receives the 1040M following the first treatment date. If 1040M is received: Within 5 business days after the first treatment date, the maximum fee is $37.84 (no payment reduction); 6-8 business days after the first treatment date, the maximum fee is $27.84; 9 or more business days after the first treatment date, the maximum fee is $17.84. Does this policy apply to self-insured employers? Yes. The full payment policy is available here
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Fee schedules updates

Fee schedule updates
Posting date	Description	Updated version
March 22, 2012	New HCPCS Codes, effective April 1, 2012	New HCPCS Codes, effective April 1, 2012
December 15, 2011	New and end dated billing codes for 2012	Additional CPT & HCPCS codes effective January 1, 2012 Comma Delimited file of Additional CPT & HCPCS codes effective January 1, 2012 CPT and HCPCS codes invalid after December 31, 2011
December 9, 2011	January 2012 ASC Fee Schedule updates - additions and deletions	January 2012 ASC Fee Schedule updates
October 24, 2011	Billing code change for the Nursing Home Fee Schedule. Group #9, Clinically Complex, will bill 8887H effective November 1, 2011	Fee Schedule Adjustment Notice
September 21, 2011	New HCPCS codes effective October 1, 2011	New HCPCS codes effective October 1, 2011
July 25, 2011	The department is updating the fees for naturopathic physicians retroactively to July 1, 2011.	Naturopathic Physician Fee Schedule Update
June 10, 2011	Additional CPT® and HCPCS codes effective July 1, 2011	Additional CPT and HCPCS codes effective July 1, 2011
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Corrections

Payment policies corrections

Payment policy corrections
Posting date	Page(s)	Description
		None at this time...
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Fee schedule corrections

Fee schedules corrections
Posting date	Description	Updated version
	None at this time...