SERVICES PROVIDED BY HOSPITAL OUTPATIENT FACILITIES AND/OR AMBULATORY SURGICAL
CENTERS: For any pathology and laboratory service(s) provided by a hospital outpatient facility and/or
ambulatory surgical center, reimbursement for said service is to be limited to the maximum allowable payment
contained within this section of the Fee Schedule.
MULTIPLE PROCEDURES: It is appropriate to designate multiple procedures that are rendered on the same
day by separate entries. Use modifier -51 to reflect multiple procedures except for the Add-On Codes.
ADD-ON CODES: Certain codes, by the nature of their description and the maximum fee assigned, have already
been reduced, as they are not to be billed as primary procedures. For a complete list of the codes which are
considered to be add-on codes, refer to the appropriate appendix found within the most recent publication of the
AMA Current Procedural Terminology (CPT).
REPORTS: No statement of charges for services or procedures included in this section shall be considered
properly rendered unless it is accompanied by a report that includes both the findings and an interpretation of
such findings.
PROCEDURES LISTED WITHOUT SPECIFIED MAXIMUM ALLOWANCE: "BR" in the Maximum Fee column
indicates that the charge for this service is to be determined "by report" because the service is too unusual or
variable to be assigned a Maximum Fee. Pertinent information should be furnished concerning the nature, extent,
and need for the procedure or service, the time, skill, and equipment necessary, etc.
INDICES OR RATIOS: Tests which produce an index or ratio based on mathematical calculations from two or
more other results may not be billed as separate independent tests (e.g., A/G ratio, free thyroxin index).
UNLISTED SERVICE OR PROCEDURE: When an unlisted service or procedure is performed, the procedure
should be identified and the amount charged substantiated "by report" (BR). Unlisted service or procedure codes
usually end in "99."
DENIAL OF PAYMENT: Payment may be denied for procedures or services determined to be excessive or
unnecessary for the management of the work-related injury or disease.
MODIFIERS: Procedure codes for pathology and laboratory services may be modified under certain
circumstances. The circumstances are to be identified by the addition of a hyphen and the appropriate two-digit
modifier code. Refer to Appendix A - Modifiers for a list of modifiers that may be used.
