NORTH CAROLINA INDUSTRIAL COMMISSION

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MEDICAL FEE SCHEDULE

Introduction

The fees set forth herein are those which are the maximum allowed to be charged for treatment of injured workers under the North Carolina Workers’ Compensation Act. If the usual and customary fees are less than this schedule, then the usual and customary fees must be used. Managed Care Organizations are not subject to the Medical Fee Schedule.

Note: To purchase a complete copy of the American Medical Association’s Current Procedural Technology Codes, telephone
OptumInsight™ at (800) 464-3649, option 1, or go to http://www.optumcoding.com/ to order a CPT® code book online.
The NC Industrial Commission Medical Fees Section is managed by Bernadine Singh, Chief Medical Fee Examiner.
Please report any problems or errors directly to Bernadine.Singh@ic.nc.gov

Table of Contents
CPT Codes and Fees
Section 1: Overview & Guidelines Section 9: Special Services
Section 2: Commission Assigned Codes Section 10: Physical Medicine
Section 3: Evaluation and Management Section 11: Chiropractic Fee Schedule
Section 4: Anesthesia Section 12: Industrial Rehabilitation
Section 5: Surgery Section 13: Dental Fee Schedule
Section 6: Radiology Section 14: Hospital and Ambulatory Surgical Center
Section 7: Pathology and Laboratory Section 15: Durable Medical Equipment/Supplies
Section 8: Medicine Section 16: Forms
This page was last updated 11 April 2013
Section 1: Overview and Guidelines

Pursuant to the authority given in N.C. Gen. Stat. §§97-26 and 97-80, the N.C. Industrial Commission has adopted the National Correct Coding Initiative Edits, effective January 1, 2010. The Correct Coding Initiative, known as CCI, was developed by the Centers for Medicare & Medicaid Services (CMS) to establish correct coding practices nationwide that would help eliminate improper coding. While the CPT coding system is used by providers to communicate payable services, payors must be able to identify comprehensive codes that describe multiple services commonly performed together. To accomplish this, CMS developed this edit system. CCI Edits are developed based on the coding conventions of the American Medical Association’s Physicians Current Procedural Terminology (CPT) book and current standards of coding practice and are updated regularly based on input from specialty societies and ongoing analysis of current coding practice.

The CPT book provides descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. A multitude of codes is necessary because of the wide spectrum of services provided by various medical providers. Because many medical services can be rendered by different methods as well as a combination of various procedures, multiple codes describing similar services are frequently necessary to accurately reflect services provided. While often only one procedure is performed at a patient encounter, it is also possible that multiple procedures be performed at the same encounter. In the latter case, a comprehensive code describing multiple services commonly performed may be defined by a CPT code.

Guidelines for Application of the Fee Schedule
  1. Reports as required by the Workers’ Compensation Act shall be made by the attending physician and hospital without extra charge.
     
  2. Original reports must show in detail the nature and extent of the injury and contain a fell description of the treatment.
     
  3. Medical providers are responsible for providing one free copy of medical records to the first requesting party among the following:  employers, carriers, third party adjusting agencies, and rehabilitation nurses.  Medical providers may charge a reasonable fee for providing medical records to each subsequent requesting party.  Medical providers may always charge a reasonable fee for providing medical records to the employee or the employee’s attorney or other representative.  The Industrial Commission has established what such reasonable fee shall be.  In no event will it be more than 50 cents per page for the first 40 pages and 20 cents per page for each page above 40, submit to a minimum fee of $10.  Such fee covers searching handling, copying and mailing.

    Upon agreement by the parties, medical records may be introduced into evidence in lieu of live testimony.  Therefore, prompt provision of the medical reports may alleviate the inconvenience to health care providers, particularly physicians, of providing live testimony.

  4. Additional Reports as Requested:  Upon request, the attending physician shall submit to the Commission and to the insurance carrier or self-insuring employer a report of progress not less often than every sixty days in cases where disability extends beyond this period.  Fees will be allowed largely upon the basis of the facts contained in the written reports rendered during the treatment of the case.  When a bill is submitted for approval, it should outline in detail the procedure for which a charge is made and show the procedure number or numbers.
     
  5. Final reports shall be filed upon forms approved by the Commission.  They shall contain a fully itemized statement of charges made and shall describe as fully as possible the nature and extent of any permanent injury or disfigurement.
     
  6. It is the duty of the attending physician to inform the Commission promptly if the claimant is found to be suffering from any disability or disease not connected with the injury sustained.
     
  7. In cases where the schedule allows a flat fee, the fee includes charges for all additional visits, dressing, treatment, and similar services.  The length of follow-up care is indicated in the schedule.  After the number of days of follow-up care have expired, additional visits should be billed for on a daily visit basis.  If care is greatly prolonged, the Commission will use its judgment in arriving at a fair fee.

    When charges are made in excess of the fee schedule allowances, complete detailed additional information must be furnished in order to justify any additional allowances.

  8. In cases where no flat fee for full treatment is prescribed herein, the commission will allow charges for frequent or protracted treatment only where the necessity is clearly shown.  The charges for such services will be adjusted as the particular case may require to produce a final and total cost reasonably comparable with a flat fee for full treatment allowed in similar cases and commensurate with the requirements of the particular case.

    UNLESS SPECIFICALLY INDICATED BY DETAILED DESCRIPTION OF THE TREATMENT, ONLY ONE VISIT PER DAY WILL BE APPROVED FOR PAYMENT.

  9. Charges for not more than thirty (30) physical therapy treatments will be approved in proper cases by the Industrial Commission without prior approval.  Charges for physical therapy treatments after the first thirty treatments will not be approved, unless previously authorized by the Commission or a copy of the referring physician’s prescription is attached to the bill and a progress report to verify the need for continuing physical therapy treatments beyond the first thirty treatments.  The charge for each individual treatment shall not be more than provided in this Fee Schedule, and further, where the total number of physical therapy treatments appears to be excessive to such extent as to make the said total fee for services burdensome to a person of like financial circumstances, the Commission will reserve the right to establish a total fee.
     
  10. Where patient is attended by more than one physician or surgeon:   Fees will not be approved for the services of more than one physician or surgeon during the same period of time unless the necessity for more than one shall be shown or such shall be ordered by the insurance carrier, the self-insuring employer, or the Commission, provided, however, that a fee not to exceed twenty per cent (20%) of the fee listed for the surgical procedure may be paid to a medical doctor who assists the surgeon in a major operation where the services of a hospital resident or staff member are not available CPT codes indicate whether an assistant surgeon is medically necessary.  Please refer to the Assistant Surgeon Guide including in the surgery section of this schedule for a listing of procedures normally appropriate for assistant surgeons.
     
  11. Where two or more physicians or surgeons not in consultation treat a single patient for whose treatment a flat fee is here prescribed, the flat fee prescribed will be allocated by the Commission between the doctors involved.
     
  12. Cases requiring special consent from the Industrial Commission or carrier.  Except in emergency or where the condition of the patient might be endangered by delay, consent from the Industrial Commission or carrier must be obtained in advance where plastic or reconstructive surgery is contemplated or where open bone surgery in the later reduction or fractures is required.  No bills for major surgery will be approved, even when authorized, until a properly executed bill is received from the hospital.
     
  13. In ambulatory cases where the surgeon is paid a fee which includes the cost of drugs and materials for dressings, and such drugs and dressings were actually furnished by a hospital, the hospital will be required to look to the surgeon for payment.
     
  14. Non-Emergency Surgical Procedures:  Charges for a major surgical operation and incidental care will not be approved unless the operation was first authorized by the Industrial Commission, insurance carrier or self-insuring employer, except in cases of emergency.
     
  15. Non-Listed Procedures.  Where proper treatment requires a particular operative procedure for which no specific fee is provided herein, the Commission will approve a fee commensurate with the procedure involved and comparable with the prescribed fee for similar or comparable procedures.
     
  16. Reports of Specialists and/or Experts:   Specialists and/or experts in special fields recognized by the American Medical Association, who make special examinations for conditions falling within the recognized field of their specialty and for which no fee is otherwise specified, herein, will be allowed a fee commensurate with the service rendered upon full explanation and report being made to the Commission.
     
  17. Early Death of Patient Following Injury:   If death occurs within one week from the date of injury, the flat-rate fee herein established will not be controlling, but the Commission will exercise its discretion to fix a reasonable fee based upon services rendered.  In all such cases, the attending physician or surgeon should submit a detailed description of the injury sustained and the service rendered.
     
  18. Plastic and Reconstructive Surgery:  Where secondary plastic and reconstructive surgery is performed, the Commission will exercise its discretion to fix a reasonable fee upon receiving a complete description of the services rendered from the surgeon performing such operation.
     
  19. Expert Witness Fees:  Fees for physicians or surgeons who appear as expert witnesses before the Industrial Commission are taxed in the costs in the case. It is unnecessary and improper for the witness to submit a bill for services rendered in such cases. Such bills will be disregarded by the Commission.
     
  20. In any case in which any item, group of items, or total charge in this fee schedule appears to be unreasonable and excessive to such an extent as to cause a hardship on people of like financial circumstances, the Commission will exercise its discretionary power to set or evaluate a total fee, notwithstanding the fact that the fees charge come within the fee schedule.
     
  21. Fees for extraordinary services.:   In cases otherwise governed by a flat-rate fee, but in which extraordinary services are required, a greater fee may be allowed. In such special hardship cases, the attending physician or surgeon must submit a detailed description of the extraordinary service rendered and the need therefore, and the Commission will exercise its discretion to fix a reasonable fee.
     
  22. Medical Personnel Pools and Treatment Procurement Programs. No fee will be approved for medical personnel pools or medical procurement programs unless prior approval is obtained for such service in writing from the workers’ compensation carrier or self-insured employer. The written authorization for such service must accompany the billing in each case where such facilities are used.
     
  23. Except in unusual cases, the Commission will not retroactively approve a change in physicians.
     
  24. If Employer and/or Insurance Company denies a Workers’ Compensation claim, a copy of From 61 and any denial letter shall be sent by Employer, or Self-Insurer/Insurance Company to Industrial Commission, Employee and all known medical providers as soon as investigation is completed. Once medical providers receive a copy of Form 612 or any denial letter, they may bill private Insurance Company or Employee. If Employee requests a hearing, the provider shall discontinue billing until after hearing is held and a final decision is made in the case after litigation is completed.
     
  25. Bill Auditing By Self-Insurers & Insurance Companies:   Self-insurers and insurance companies may request a medical bill be audited by private auditors if they feel it necessary. They must first submit the medical bill to the North Carolina Industrial Commission for approval or reduction by the medical fee schedule, pay the provider amount approved by the Commission for approval or reduction by the medical fee schedule, pay the provider amount approved by the Commission and then request an audit. The medical provider may make no charge for such audit or for necessary copies of bills involved in such audit. If errors are found, a corrected bill must be submitted back to the Commission with a copy of the bill analysis for our correction.

    If self-insurers or insurance companies review a medical bill and find charges that are not work related, they must return the bill to the provider and request that the bill be resubmitted with only the work related charges. The bill may at that time be submitted to the Commission for approval.

  26. Assistant Surgeon Fee:   Surgical Assistant services rendered by a licensed physician who assists the treating physician in a surgical procedure, where the services of a hospital resident or staff member are not available, may not exceed twenty per cent (20%) of the fee listed for the surgical procedure. If the treating physician feels that the use of a assistant is warranted, the request for assistant’s fee must be accompanied by a notation on the Form 25M and/or HCFA 1500 and a memorandum from the physician detailing the need. Physician Assistants (PAs) are entitled to 17 percent of the fee schedule. Nurse assistants are not billable for assisting in surgery in Workers’ Compensation Cases. CPT codes indicate whether an assistant surgeon is medically necessary.
     
  27. Travel Reimbursement, N.C. Gen. Stat. §97-25:   Employees are entitled to collect for mileage for medical treatment in workers’ compensation cases at the rate of 55 cents per mile since January 1, 2009, providing they travel 20 miles or more roundtrip. Special consideration will be given to employees who are totally disabled. These charges should be reported on the North Carolina Industrial Commission Form 25T.

    No allowance will be made for trips to drugstore for drugs or medical supplies unless medically necessary. Must purchase these items on visit to medical provider.

  28. Other Expenses:  If overnight stay is medically necessary, the self-insurer or insurance carrier is liable for travel, motel, food, parking and cab expenses only for the employee.(Except in some cases dealing with employees who are totally disabled.) Employees who are totally disabled and requiring assistance should seek prior approval from the self-insurer or insurance carrier for amount to be reimbursed. The Charges listed below are GUIDELINES for the self-insureds and carriers to follow and may be exceeded without approval from Industrial Commission. Receipts must be furnished for carrier’s file. Meals are not covered for day trips. These charges should be reported on North Carolina Industrial Commission Form 25T and may be paid by the self-insurer or insurance carrier without the approval of the Commission. Retain a copy for your file.
    a. Motel $45.00
    b. Meals             Breakfast $  6.00
                               Lunch $  8.00
                               Dinner $14.00
    c. Parking & Cab Expenses Actual Chg
How to Interpret the Fee Schedule Data

There are six columns used throughout the North Carolina Workers’ Compensation Medical Fee Schedule with the following column headings:

TOTAL FEE   This manual lists the total reimbursable as a monetary amount. There are, however, procedures to variable to accept a set value – these are “By Report” procedures and are noted BR.
FUD   Follow-up days included in a surgical procedure’s global charge are listed in this column. In counting follow-up days, day one is the day of surgery, not the discharge day.
PC FEE   Where there is an identifiable physician and technical component, The portion considered to be the physician component (PC) is listed. The physician component gives the total reimbursable as a monetary amount; you may use modifier –26 to report these services.
TC FEE   Where there is an identifiable technical and physician component, the portion considered to be the technical component (TC) is listed. The technical component gives the total reimbursement as a monetary amount; you may use modifier –27 to report these services.
PC/TC   A value is now assigned for each code with a split technical/professional component.
CODE   This column lists the American Medical Association’s (AMA) CPT code. The current CPT is used by arrangement with the AMA. Please refer to the CPT manual for symbol designating new codes.
DESCRIPTION   This manual uses Current Procedural Terminology, a product of the American Medical Association. Full descriptions are no longer presented in the Fee Schedule. Please refer to the CPT manual for this information.
Effective March 1, 2001, the Commission deletes all CPT codes not found in the current AMA listings. Furthermore, the Commission will annually adopt new codes as well as delete old codes as released by the American Medical Association.
ADDENDUM

Guidelines Subsequent to 1996 Fee Schedule

On March 1, 1996, the N.C. Industrial Commission (NCIC) started processing medical bills using the 1996 Medical Fee Schedule. Since that time, at least eight updates have been issued. In most cases, the Medical Fee Section processes medical bills using the most current Fee Schedule. However, the Commission will be glad to review any medical bills in question in accordance with the service date and applicable schedule for that time period (ex. Older bills from litigated case). 

When parties other than the Commission are responsible for processing physician or professional medical bills, the Current Procedural Terminology (CPT) codes may be changed only after discussing the proposed change with the Medical Provider and obtaining an agreement that it can be changed. The medical bill analysis shall clearly show that the CPT code was changed and shall state the reason.

Questions regarding the application of the Fee Schedule may be directed to the North Carolina Industrial Commission Medical Fees Section.

N.C. Industrial Commission
Medical Fees Section
4337 Mail Service Center
Raleigh, NC 27699-4337
(919) 807-2503
COMMENTS

Codes considered approved “BY REPORT” must be sent to the Chief Medical Fee Examiner marked “PERSONAL”.  These bills will be entered into our system and returned to the Insurance Company or Self-Insurer. They must contain the I.C. file number, carrier code number and employer code number.

The Industrial Commission has given permission for the processor to pay bills that are listed “BY REPORT” if charges don’t exceed $50.00 without submitting them to the Industrial Commission.

The Industrial Commission does not allow for acupuncture, “no show” visits, or cancelled surgeries. Massage Therapy by a licensed massage therapist is paid per agreement.

CPT only Copyright ©2004 American Medical Association. All Rights Reserved.