AMBULATORY SURGICAL CENTERS

 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. 

PATHOLOGY AND LABORATORY GROUND RULES

 SEROLOGY: All serological procedures must be performed by registered pathologists or laboratories. 

 MATERIALS SUPPLIED BY HEALTH CARE PROVIDER: Supplies and material provided by the health care provider (e.g., sterile trays, drugs) over and above those usually included with the office visit or other services rendered may be listed separately. The statement of charges will need to list individually any drugs, trays, supplies, and materials that were provided. Payment shall not exceed the cost of the item(s) to the health care provider plus 25%, or the cost of the item(s) plus $15.00 per item, whichever is less. Use procedure code 99070. 

MAXIMUM FEES: The Maximum Fees specified herein apply to laboratories owned or operated by a health care provider, hospital laboratories, and commercial laboratories, but only when the services or procedures are performed by or under the responsible supervision of a health care provider. When a health care provider is hospital based and is not salaried or otherwise compensated for the services listed in this section, a separate bill can be rendered for the particular service. The charge is to be 60% of the Maximum Fee. 

The Maximum Fees specified herein include both the "professional" component and the "technical" component. Identification of a service or procedure by its five-digit code, without pertinent modifiers, indicates that the charge includes both the professional and technical components. Where the maximum fee is “0” for either the professional component or the technical component there is no designated payment allowed. 

The professional component includes the examination of the patient when indicated, performance or supervision of the procedure, interpretation and written report of the examination including procedure results (e.g., x-ray images), and consultation with the referring health care provider. To identify a charge for the professional component only, see Appendix A - Modifiers for modifier -26. Unless otherwise specified in the Schedule, the maximum allowable charge for the professional component is 60% of the listed Maximum Fee in the ATS@ column. 

Nuclear Medicine and Diagnostic Ultrasound

 ADD-ON CODES: Certain codes, by the nature of their description and the maximum fees 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). 

MATERIALS SUPPLIED BY HEALTH CARE PROVIDER: Supplies and materials provided by the health care provider (e.g., sterile trays, drugs) over and above those usually included with the office visit or other services rendered may be listed separately. The statement of charges will need to reflect any drugs, trays, supplies, and materials that were provided. Payment shall not exceed the cost of the item(s) to the health care provider plus 25% of the cost or the cost of the item(s) plus $15.00 per item, whichever is less. Use procedure code 99070. The Maximum Fees in this section do not include radiopharmaceutical or other radionuclide material costs. List the name and dosage of radiopharmaceutical material and cost. 

 INJECTION PROCEDURES: Charges for injection procedures are to include all usual pre- and post-injection care specifically related to the injection procedure, necessary local anesthesia, placement of needle or catheter, and injection of contrast media. Vascular injection procedures are listed under the Cardiovascular Subsection of the Surgery Section, procedure codes 36000-36299. Other injection procedures are listed in pertinent sections. 

PROCEDURES LISTED WITHOUT SPECIFIED MAXIMUM ALLOWANCE: "BR" in a maximum fee column indicates that the amount charged 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. Additional items which may be helpful might include: complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care. 

 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." 

MODIFIERS: Procedure codes for radiology 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. 

RADIOLOGY GROUND RULES

DUPLICATION OF X-RAYS: Every attempt should be made to minimize the number of x-rays taken. The attending health care provider or any other person or institution having possession of x-rays, which pertain to the patient and are deemed to be needed for diagnostic or treatment purposes, should make those x-rays available upon request. No payments shall be made for additional x-rays when recent x-rays are available, except when the charge is supported by adequate information regarding the need to perform another x-ray. 

PHOTOGRAPHIC MEDIA: The use of photographic media or imaging is not reported separately but is considered to be a component of the basic procedure and shall not merit any additional payment.

 XERORADIOGRAPHY: Imaging performed by this process shall have the same Maximum Allowable Fees as those listed for conventional x-ray procedures of the same anatomical area and views. 

 MAXIMUM FEES: The Maximum Fees contained within this fee schedule include both the "professional component” and the "technical component”. Identification of a service or procedure by its five digit code, without pertinent modifiers, indicates that the services provided include both the professional and technical components. Where the value is “0” for either the professional component or technical component there is no designated payment allowed. The professional component includes the examination of the patient when indicated, performance or supervision of the procedure, interpretation and written report of the examination including procedure results (e.g., x-ray images), and consultation with the referring health care provider. The value is shown in the “PC” column of this fee schedule. The technical component includes the charges for personnel, materials and other supplies, and space, equipment, and other facilities, but excludes the cost of radioisotopes. The value is shown in the “TC” column of this fee schedule. The total services component includes both the professional component and the technical component. The value is shown in the “TS” column of this fee schedule. Hospital outpatient facilities and ambulatory surgical centers must specify, by use of modifiers, when only the technical component or the professional component is provided. 

SERVICES PROVIDED BY A HOSPITAL OUTPATIENT FACILITY AND/OR AMBULATORY SURGICAL CENTER: For any radiology 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. 

Surgery

10021 XXX $312.27 

10022 XXX $292.94 

10030 XXX $1,640.90 

10040 10 $211.15 

10060 10 $241.64 

10061 10 $429.74 

10080 10 $373.24 

10081 10 $565.80 

10120 10 $316.73 

10121 10 $573.98 

10140 10 $339.78 

10160 10 $271.38 

10180 10 $515.99 

11000 0 $113.76 

11001 ZZZ $44.61 

11004 0 $1,234.21 

11005 0 $1,662.47 

11006 0 $1,495.92 

11008 ZZZ $582.90 

11010 10 $1,020.08 

11011 0 $1,127.89 

11012 0 $1,490.72 

11042 0 $243.12 

11043 0 $482.53 

11044 0 $669.15 

11045 ZZZ $89.22 

11046 ZZZ $154.65 

11047 ZZZ $263.94 

11055 0 $98.89 

11056 0 $121.19 

11057 0 $136.80 

11100 0 $212.64 

11101 ZZZ $67.66 

11200 10 $182.90  

11201 ZZZ $40.15  

11300 0 $199.26 

11301 0 $245.36  

11302 0 $289.22 

11303 0 $321.19 

11604 10 $653.54

11603 10 $585.13

11602 10 $513.02

11951 0 $217.10

11601 10 $472.87 

11601 10 $472.87 

11950 0 $159.11

11600 10 $400.00

11922 ZZZ $128.63

11922 ZZZ $128.63

11471 90 $1,073.61

11921 0 $416.36

11470 90 $865.43 

11920 0 $358.37

11463 90 $1,031.98

 11901 0 $144.98

11462 90 $768.78 

11900 0 $114.50

11451 90 $1,008.19 

11772 90 $1,449.08

11450 90 $787.37 

11446 10 $818.59 

11770 10 $579.19

11444 10 $588.85 

11765 10 $346.47

11443 10 $466.17 

11442 10 $391.08 

11762 10 $591.08

11760 10 $485.51

11441 10 $349.45 

11440 10 $281.04 

11426 10 $695.17 

11755 0 $279.56

11750 10 $468.41

11752 10 $673.61

11424 10 $484.76 

11740 0 $103.35

11423 10 $420.08 

11732 ZZZ $74.35

11422 10 $364.32 

11730 0 $206.69

11421 10 $326.40 

11721 0 $93.68

11420 10 $253.53 

11720 0 $67.66

11305 0 $203.72 

11606 10 $936.81

11306 0 $250.56 

11620 10 $404.46

11307 0 $295.91

 11621 10 $475.84

11308 0 $311.53 

11622 10 $530.86

11406 10 $651.31 

11719 0 $29.00

11404 10 $450.56 

11646 10 $1,078.82

11403 10 $397.03 

11644 10 $823.80

11402 10 $342.75 

11643 10 $667.66

11401 10 $307.81 

11642 10 $562.09

11400 10 $254.28 

11641 10 $493.68

11313 0 $384.39 

11640 10 $416.36

11312 0 $330.86 

11626 10 $852.79

11311 0 $229.00 

11624 10 $704.84

11310 0 $233.46 

11623 10 $624.54

69650 90 $1,722.69

69405 10 $558.37 

69420 10 $408.18 

69661 90 $2,586.64

69421 10 $318.22 

69662 90 $2,476.60

69424 0 $271.38 

69666 90 $1,733.10

69433 10 $432.72 

69667 90 $1,736.07

69436 10 $343.50 

69670 90 $2,023.06

69440 90 $1,478.08 

69676 90 $1,782.17

69450 90 $1,165.81 

69700 90 $1,469.90

69501 90 $1,568.79 

69710 XXX $0.00

69502 90 $2,084.77 

69711 90 $1,848.34

69505 90 $2,565.82 

69714 90 $2,306.34

69511 90 $2,628.27 

69715 90 $2,848.35

69530 90 $3,525.68 

69717 90 $2,420.84

69535 90 $5,733.87 

69718 90 $2,878.09

69540 10 $445.36 

69720 90 $2,558.38

69550 90 $2,219.35 

69725 90 $4,032.74

69552 90 $3,349.47 

69740 90 $2,503.36

69554 90 $5,387.40 

69745 90 $2,662.47

69601 90 $2,243.14 

69799 YYY $0.00

69602 90 $2,333.10 

69801 0 $418.59

69603 90 $2,686.27 

69805 90 $2,260.98

69604 90 $2,384.40 

69806 90 $2,030.50

69605 90 $3,326.42 

69820 90 $1,837.93

69610 10 $820.82 

69620 90 $1,471.39 

69905 90 $1,968.79

69840 90 $1,898.16

69631 90 $1,894.44 

69910 90 $2,182.17

69632 90 $2,311.54 

69915 90 $3,303.37

69633 90 $2,235.70 

69930 90 $2,626.04

69635 90 $2,627.53

 69949 YYY $0.00

69636 90 $2,940.54 

69950 90 $3,823.08

69637 90 $2,930.88 

69955 90 $4,243.90

69641 90 $2,232.73 

69960 90 $4,128.66

69642 90 $2,866.19 

69970 90 $4,596.32

69643 90 $2,623.81 

69979 YYY $0.00

69644 90 $3,151.70 

69990 ZZZ $461.71

69660 90 $1,985.89

SURGERY GROUND RULES

SURGERY AND FOLLOW-UP CARE PROVIDED BY DIFFERENT HEALTH CARE PROVIDERS: When one health care provider performs the surgical procedure and another provides the follow-up care, the value may be apportioned between them by agreement. Whether the amount charged is for the procedure, or the follow-up care should be clearly indicated. The "global fee" is not to be increased, but prorated between the health care providers.

REPEAT PROCEDURE BY ANOTHER HEALTH CARE PROVIDER: A basic procedure performed by one health care provider may have to be repeated by another. Identify and submit an explanatory note. 

PRORATION OF SCHEDULED FEE: When the schedule specifies a unit value for a definite treatment and the patient is transferred from one health care provider to another, the applicable Unit Value is to be apportioned between the health care providers. The providers involved shall agree upon the amount of the proration, and shall render separate bills accordingly with an explanatory note.  

MATERIALS SUPPLIED BY HEALTH CARE PROVIDER: Supplies and materials provided by the health care provider (e.g., sterile trays, drugs) over and above those included with the office visit or other services rendered may be listed separately. The statement of charges will need to reflect any drugs, trays, supplies, and materials provided. Payment shall not exceed the cost of the item(s) to the health care provider plus 25%, or the cost of the item(s) plus $15.00 per item, whichever is less. Use procedure code 99070. 

 SURGICAL IMPLANTABLES: Reimbursement for surgical implantable items (e.g. rods, pins, screws, plates, prosthetic joint replacements) and which are made of plastic, metallic, or of autogenous/non-autogenous graft material are to be determined by cost to the provider plus a 25% markup above the invoice cost. A copy of the invoice(s) (date of purchase within twelve months of implantation) must be submitted with the bill. Costs of postage and delivery are not reimbursable.

SURGICAL ASSISTANT: Non-physician surgical assistants such as physician assistants or registered nurses, who are either certified or licensed by the Kansas State Board of Healing Arts, the Kansas State Board of Nursing, or some other comparable State licensing agency, may bill at 10% of the code fee. The code(s) must coincide with those of the primary surgeon who must be identified as the responsible physician. Such services are to be identified by adding modifier -NP to the procedure code. 

Additionally, bills for any other surgical services (i.e. repair of a minor laceration) provided by non-physicians such as physician assistants or registered nurses must be submitted on the CMS 1500 or an equivalent form containing the same information. The form must also clearly identify the responsible physician.

OTHER FEES: The Unit Values for anesthesia, x-rays, laboratory procedures, consultation and other medical services, and office and hospital visits are listed in the following sections: Anesthesia, Radiology, Pathology and Laboratory, Medicine, Physical Medicine and Rehabilitation, and Evaluation and Management.  

MEASUREMENTS: When listed with a described procedure, measurements pertain to the original wounds or defects before any treatment is effected. The allowable charge includes creation of any additional defect. The necessary preparations for repair do not merit an additional charge. The depth of a wound is not a factor in the measurements when the described procedure is stated in terms of length or area. 

MODIFIERS: Procedure codes for surgery 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.

UNLISTED SERVICE OR PROCEDURE

PRIMARY, SECONDARY, OR DELAYED PROCEDURES: A primary procedure is one that is attempted or performed for the first time, irrespective of the relationship to the date of injury or the onset of the condition being treated. Secondary refers to a procedure performed when a condition has been previously treated. For example, where a tendon is lacerated and it is elected to close the laceration without suturing the tendon, the first direct repair of the tendon would constitute a delayed but primary repair. In this example, if the first repair is unsuccessful, any subsequent repair of the tendon would be a secondary procedure. Secondary procedures lie within the content of service. Delayed procedures have the same Maximum Allowable Fee as the primary procedures. 

 PROCEDURES LISTED WITHOUT SPECIFIED MAXIMUM ALLOWANCE: "BR" in the Unit Value column indicates that the amount charged for this service is to be determined "by report" because the service is too unusual or variable to be assigned a Unit Value. Pertinent information should be furnished concerning the nature, extent, and need for the procedure or service, the skill and equipment necessary, etc., using any of the following as indicated: 

Diagnosis (postoperative), pertinent history, and physical findings 

Size, location, and number of lesions or procedures where appropriate 

Major surgical procedure accompanied by an additional procedure 

The closest similar procedure by code number and the associated Unit Value, if possible Operative time 

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." 

CONCURRENT SERVICES BY MORE THAN ONE HEALTH CARE PROVIDER: Charges for concurrent services of two or more health care providers may be warranted under the following circumstances: 

a) Identifiable medical services: Services provided prior to or during the surgical procedure or in the postoperative period are to be charged by the health care provider rendering the service, identified by the appropriate code. Payable fees under this category are unrelated to the surgeon's fee.

b) Assistant surgeon: Identify the surgery performed by using the respective code number along with the appropriate modifier (-80, -81, or -82) and bill at 25% of the code fee. The code number must coincide with that of the primary surgeon. Assistant surgeon fees are not payable when the hospital provides an intern or a resident staff to assist at surgery. 

c) Two surgeons: Under certain circumstances, the skills of two surgeons (usually with different skills) may be required in the management of a specific surgical procedure. Identify the surgery performed by using the respective code number along with modifier -62. The total allowable fee may be increased by 25% in lieu of an assistant surgeon=s fee. If the physicians have agreed upon a payment distribution and that agreement is documented and explained in conjunction with the bill, payment is to be made in accordance with the percentage agreed upon. 

MULTIPLE/BILATERAL EXAMPLES

ADD-ON CODES: Certain codes, by the nature of their description and the unit values 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). 

CODES THAT ARE NOT CLASSIFIED AS ADD-ON CODES BUT ARE EXEMPT FROM THE MULTIPLE PROCEDURE RULE / MODIFIER -51: For a complete list of the codes which fall into this category, refer to the appropriate appendix found within the most recent publication of the AMA Current Procedural Terminology (CPT).

CODES WHICH INCLUDE CONSCIOUS SEDATION: Certain codes include conscious sedation as an inherent part of providing the procedure. For a complete list of codes that include conscious sedation, refer to the appropriate appendix that is found within the most recent publication of the AMA Current Procedural Terminology (CPT).

FOLLOW-UP OR AFTERCARE: Follow-up care for therapeutic surgical procedures includes all normal postoperative care, that care which is usually a part of the surgical service. Complications, exacerbations, recurrence of the condition, or the presence of other diseases or injuries requiring additional services concurrent with the procedure may warrant additional charges. If such separate charges are made, explain by report with an adequate description. When an additional surgical procedure is performed during any follow-up care and is related to the previously performed procedure but is not an intrinsic part of the latter, the additional procedure will be paid at one-half the maximum allowable payment.  

Schedule of Medical Fees

The Kansas Workers Compensation Schedule of Medical Fees has utilized portions of the following documents:

1. The Current Procedural Terminology, Fourth Edition, copyright 2014 (a.k.a. CPT 2013) by the American Medical Association 

2. The CDT(Current Dental Terminology) Companion, CDT-2013/2014, copyright 2012, published by the American Dental Association 

3. The 2014 Relative Value Guide, copyright 2012, developed by the American Society of Anesthesiologists 

4. The 2014 Essential RBRVS, a comprehensive listing of RBRVS values for CPT and HCPCS Codes, copyright 2013 Ingenix.

5. The January 2014 HCPCS allowances that were obtained from the DMEPOS Fee Schedule of the Centers for Medicare & Medicaid Services (CMS). 

6. Medicare Severity Diagnosis Related Groups (MS-DRGs) Definitions Manual, Version 31.  

Some of the most important revisions that have been utilized within this Schedule of Medical Fees are as follows:

1. The Conversion Factors for all CPT codes in the Medicine and Evaluation and Management Sections have been increased by 3%. 

2. ICD-10 is not mandated by Kansas Workers Compensation. However, it is strongly recommended that ICD-10 be employed for billing purposes on the CMS 1500 Form or an equivalent form containing the same information. 

3. Surgical CPT code 36415 has been moved to the Pathology and Laboratory Section of the fee schedule. 

4. Trauma Alerts in Ground Rule 7 of Inpatient Hospital and Ground Rule 4 of Ambulatory Surgical Centers/Hospital Outpatient are increased by 7%.

5. Compound drugs and physician dispensed medications shall be reimbursed the same as pharmacies based on the original manufacturer NDC but must be preapproved by the payer. 

6. An inpatient stay requires documentation of official admission to the hospital pursuant to an order for inpatient admission by a physician or other qualified practitioner and the order must be present in the medical record.