| Fee Schedule look-up |
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 all bills with place-of-service codes 11 (Office), 15 (Mobile Unit) and 20 (Urgent Care Facility) for all in-state and out-of-state practitioners.
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Facility fee - The reimbursement fee for all bills with place-of-service codes other than 11 (Office), 15 (Mobile Unit) and 20 (Urgent Care Facility) for all in-state and out-of-state practitioners
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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.
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The MCO must obtain a report for reimbursement consideration. Authorization and payment of codes identified as -BR require an individual analysis by the MCO prior to submission. The MCO analysis shall include researching the appropriateness of the code in relation to the service or procedure and cost comparisons in order for the MCO to approve high quality, cost-effective medical care. The MCO must submit the research to the BWC medical policy department with each request. After review by the MCO, the report must be imaged into the BWC claim and a request must be submitted, utilizing the sensitive data transmission policy, to the BWC medical policy e-mail box, Medpol@bwc.state.oh.us, for an adjustment to be processed.
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MCOs should note that most CPT codes have an assigned Relative Value Unit (RVU) which must be used to determine reimbursement. Fees for CPT codes that do not have an established RVU must be compared to a like service to assist in determining appropriate fees. HCPCS codes are priced through multiple cost comparisons.
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Not covered (NC) - The procedure or service is not covered unless application of the Miller criteria requires an exception.
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Negotiated - Designated all-inclusive per diem codes require negotiated reimbursement rates. 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 reimbursements rates may often be necessary.
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Modifier 22 - Unusual procedural services. Modifier 22 must include a report documenting circumstances for its use. Reimbursement is 120 percent 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 - Bilateral procedure. Reimbursement is 150 percent of fee schedule amount.
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Modifier 52 - Reduced Services. Reimbursement is 50 percent of fee schedule amount.
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Modifier 53 - Discontinued procedures. Reimbursement is 50 percent 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 - Surgical care only. Reimbursement is 70 percent of fee schedule amount.
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Modifier 55 - Post operative management only. Reimbursement for all post -op care is 20 percent of fee schedule amount
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Modifier 56 - Pre-operative management only. Reimbursement is 10 percent of fee schedule amount.
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Modifier 62 - Two surgeons. Reimbursement is 62.5 percent of fee schedule amount to each surgeon.
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Modifier 80 - Assistant surgeon reimbursement is 20 percent of fee schedule amount.
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Modifier 81 - Minimum assistant surgeon reimbursement is 10 percent of fee schedule amount.
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Modifier 82 - Assistant surgeon (when qualified resident surgeon is not available). Reimbursement is 20 percent of fee schedule amount.
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Modifier RB - Replacement of a part DME furnished as part of a repair
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Modifier RR - Rental equipment component reimbursement
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Modifier NU - New equipment
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Modifier TC - Technical component reimbursement. Payment rates vary according to the RVU assigned to the CPT code when modified.
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