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This Inpatient Hospital Fee
Schedule is applicable for all inpatient medical, surgical,
rehabilitation, and/or psychiatric services rendered in a hospital
to injured workers under the ARKANSAS WORKERS' COMPENSATION
ACT. This Inpatient Hospital Fee Schedule is established
pursuant to ARK. CODE ANN. 11-9-517 (1987).
I. GENERAL GROUND RULES
A. General Information
1. Reimbursements shall be determined
for services rendered in accordance with this fee schedule
and shall be considered to be inclusive unless otherwise
noted.
2. Reimbursement for a compensable workers'
compensation claim shall be the lesser of the hospital's
usual and customary charges or the maximum amount allowed
under the Inpatient Fee Schedule.
3. All inpatient hospital care must
be reviewed under the PROFESSIONAL HEALTH CARE REVIEW
PROGRAM required by COMMISSION RULE 30.
4. Inpatient hospitals shall be grouped
into the following separate peer groupings:
PEER GROUP 1
HOSPITALS 1 - 49 BEDS
PEER GROUP 2
HOSPITALS 50 - 99 BEDS
PEER GROUP 3
HOSPITALS 100 - 199 BEDS
PEER GROUP 4
HOSPITALS 200 - 399 BEDS
PEER GROUP 5
HOSPITALS 400+ BEDS
PEER GROUP 6
REHABILITATION HOSPITALS
PEER GROUP 7
PSYCHIATRIC HOSPITALS
5. For each inpatient claim submitted,
the provider shall assign a DIAGNOSIS RELATED GROUP (DRG)
code from the attached listing which appropriately reflects
the patient's primary cause of hospitalization.
6. The inpatient hospital fee schedule
shall become effective SEPTEMBER 15, 1993
and shall be updated annually.
7. Ongoing analysis will be conducted
as to the projected savings of this schedule, as well as
any impact on patient services. (An overall review of this
schedule will be conducted within 6 months of implementation
date.)
8. Preauthorization is required for
specific inpatient services.
B. Definitions
DRG - One of 492 classifications
of diagnosis in which patients demonstrate similar resource
consumption and length of stay patterns.
INPATIENT SERVICES
- Services rendered to a person who is formally admitted
to a hospital and whose length of stay exceeds 23 hours.
INSTITUTIONAL SERVICES
- All non-physician services rendered within the institution
by an agent of the institution.
LENGTH OF STAY (LOS)
- Number of days of admission where patient appears on midnight
census. Last day of stay shall count as an admission day
if it is medically necessary for the patient to remain in
the hospital beyond 12:00 noon.
MEDICAL ADMISSION
- Any hospital admission where the primary services rendered
are not surgical, psychiatric, or rehabilitative in nature.
STOP-LOSS PAYMENT (SLP)
- An independent method of payment for an unusually costly
or lengthy stay.
STOP-LOSS REIMBURSEMENT FACTOR
(SLRF) - A factor established by the Commission
to be used as a multiplier to establish a reimbursement
amount when total hospital charges have exceeded specific
stop-loss thresholds.
STOP-LOSS THRESHOLD (SLT)
- Threshold of total charges established by the Commission,
beyond which reimbursement is calculated by multiplying
the applicable Stop-Loss Reimbursement Factor times the
total charges identifying that particular threshold.
SURGICAL ADMISSION
- Any hospital admission where the primary services rendered
are not medical, psychiatric or rehabilitative in nature.
TRANSFERS BETWEEN FACILITIES
- To move or remove a patient from one facility to another
for a purpose related to obtaining or continuing medical
care. May or may not involve a change in the admittance
status of the patient, i.e. patient transported from one
facility to another to obtain specific care, diagnostic
testing, or other medical services not available in facility
in which patient has been admitted. Includes costs related
to transportation of patient to obtain medical care [Medical
Dispute Resolution definition derived from the definition
provided for "transfer" in the Black's Law
Dictionary, 5th Edition, ed. Henry Campbell Black, M.A.
(St. Paul, MN: West Publishing Company, 1979)].
WORKERS' COMPENSATION STANDARD
PER DIEM AMOUNT (SPDA) - A standardized per
diem amount established for the reimbursement of hospitals
for services rendered.
II. SPECIAL GROUND RULES - INPATIENT HOSPITAL
SERVICES
This section defines the reimbursement procedures
and calculations for inpatient health care services by all hospitals.
A. General Information
1. For each inpatient claim submitted,
the provider shall assign a DIAGNOSIS RELATED GROUP (DRG)
code from the attached listing which appropriately reflects
the patient's primary cause for hospitalization. Hospitals
within each peer group shall be paid a maximum amount per
inpatient day.
2. The maximum per diem rate to be used
in calculating the reimbursement rate is as follows:
PEER GROUP 1
$ 828.00
PEER GROUP 2
969.00
PEER GROUP 3
1,180.00
PEER GROUP 4
1,338.00
PEER GROUP 5
1,567.00
PEER GROUP 6
1,166.00
PEER GROUP 7
677.00
3. The Inpatient Fee Schedule allows
for independent reimbursement on a case-by-case basis if
the particular care exceeds the Stop-Loss Threshold.
B. Reimbursement Calculations
1. Explanation
a. Each admission is assigned an appropriate
DRG.
b. The applicable Standard
Per Diem Amount (SPDA) is
multiplied by theLength Of Stay (LOS)
for that admission.
c. The Workers' Compensation
Reimbursement Amount (WCRA) is the
total amount of reimbursement to be made for that particular
admission.
2. Formula
LOS X SPDA = WCRA
3. Example
DRG 222: KNEE PROCEDURES W/O
CC
HOSPITAL PEER GROUP: 3
MAX. RATE PER DAY: $1,180
NUMBER BILLED DAYS: 9
BILLED CHARGES: $21,750
Maximum Allowable Payment: $10,620
C. Stop-Loss Method
Stop-loss is an independent reimbursement
factor established to ensure fair and reasonable compensation
to the hospital for unusually costly services rendered during
treatment to an injured worker.
1. Explanation
a. To be eligible for stop loss payment,
the total allowed charges for a hospital admission must
exceed the hospital maximum payment, as determined by
the hospital maximum payment rate per day, by at least
$10,000.
b. This stop-loss threshold is established
to ensure compensation for unusually extensive services
required during an admission.
c. Once the allowed charges reach
the stop-loss threshold, reimbursement for all additional
charges shall be made based on a stop-loss payment factor
of 80%.
d. The additional charges are multiplied
by the Stop-Loss Reimbursement
Factor (SLRF) and added to the maximum allowable
payment.
2. Formula
(ADDITIONAL CHARGES X SLRF) + MAXIMUM
ALLOWABLE PAYMENT = WCRA
3. Example
DRG 222: KNEE PROCEDURES W/O CC
HOSPITAL PEER GROUP: 3
MAX. RATE PER DAY: $1,180
NUMBER BILLED DAYS: 9
BILLED CHARGES: $21,750
Maximum Allowable Payment For
Normal DRG Stay
$10,620
Versus: Billed Charges $21,750
Amount Payable Before Stop-Loss,
Lower of Charge vs Maximum Allowable...........................................
$10,620
Total Difference,
Charges vs Payments $11,130
Difference Over & Above $10,000
Stop-Loss, $1,130
Payable at 80%..................................... $
904
TOTAL PAYMENT
DUE HOSPITAL
$11,524
D. Billing For Inpatient Admissions
1. All bills for inpatient institutional
services should be submitted on the standard UB-82 (HCFA
1450) form or any revision to that form.
III. PREAUTHORIZATION
A. Procedures For Requesting
Preauthorization
1. The insurance carrier is liable for
the reasonable and necessary medical costs relating to the
health care treatments and services listed in subsection
(7) of this section required to treat a compensable injury,
when any of the following situations occur:
(a) there is a documented life-threatening
degree of a medical emergency necessitating one of the
treatments or services listed in subsection (7) of this
section;
(b) the treating doctor, his/her designated
representative, or injured employee has received preauthorization
from the carrier prior to the health care treatments or
services; or
(c) when ordered by the Commission.
2. The insurance carrier shall designate
an accessible direct telephone number, and may also designate
a facsimile number for use by the treating doctor or the
injured employee to request preauthorization during normal
business hours. The direct number shall be answered or the
facsimile responded to, by the carrier's agent who is delegated
to approve or deny requests for preauthorization, within
the time limits established in subsection (4) of this section.
3. Prior to the date of proposed treatment
or services, the treating doctor, or his/her designated
representative, shall notify the insurance carrier's delegated
agent, by telephone or transmission of a facsimile, of the
recommended treatment or service listed in subsection (7)
of this section. Notification shall include the medical
information to substantiate the need for the treatment or
service recommended. If requested to do so by the carrier,
the treating doctor shall also notify the insurance carrier
of the location and estimated date of the recommended treatment
or service, and the name of the health care provider performing
the treatment or service, if other than the treating doctor.
Designated representative includes, but is not limited to,
office staff, hospitals, etc.
4. Within three working days of the
treating doctor's request for preauthorization, the insurance
carrier's delegated agent shall notify the treating doctor,
by telephone or transmission of a facsimile, of the insurance
carrier's decision to grant or deny preauthorization. When
the insurance carrier approves preauthorization, the insurance
carrier shall send written approval, or if denying preauthorization,
shall send documentation identifying the reasons for denial.
Notification shall be sent to the injured employee, the
injured employee's representative if known, and the treating
doctor, or the treating doctor's designated representative,
within 24 hours after notification of denial or approval.
5. The insurance carrier must maintain
accurate records to reflect information regarding the preauthorization
request and approval/denial process.
6. If a dispute arises over denial of
preauthorization by the insurance carrier, the doctor or
the injured employee may proceed to Preauthorization Medical
Dispute Resolution.
7. The health care treatments and services
requiring preauthorization are: all nonemergency hospitalizations,
and transfers between facilities.
8. A failure to respond and a denial
of a preauthorization request must be handled according
to the following procedures:
a. When an insurance carrier or self-insured
employer fails to respond to a preauthorization request,
the treating doctor or designated representative must
call the Medical Cost Containment Division with detailed
information if:
(1) Verbal response is not received
within 3 working days from date of completed request
(do not count first day);
(2) Written confirmation is not
sent within 24 hours from verbal notification.
b. When a request for pre-authorization
is denied, a request for review may be submitted to the
Medical Cost Containment Division of the Arkansas Workers'
Compensation Commission.
(1) All documents and copies of
documents submitted as part of the request shall be
legible. The request shall include the following information:
(a) The claimant's full name,
address, and social security number;
(b) the workers' compensation
number assigned to the claim by the commission, if
known;
(c) the date and nature of the
injury or illness;
(d) the employer's name and address;
(e) the insurance carrier's name
and address;
(f) the health care provider's
name, address, Federal Tax Identification number,
and professional license number;
(g) copies of all written communications
and memoranda relating to the dispute;
(h) documentation indicating efforts
have been made to attempt to resolve this dispute
between the parties;
(i) copies of all medical bills,
which are disputed, as originally submitted to the
insurance carrier;
(j) a summary of the requesting
party's position regarding the dispute; and
(k) the date of this request.
(2) On the same date of submission
to the commission, the requesting party shall send a
copy of the request, by certified mail, to the responding
party, hereafter referred to as "RESPONDENT".
(3) When the request is received
by the Medical Cost Containment Division, all parties
will be notified by certified mail, return receipt requested.
All parties shall have thirty (30) days from the date
of receipt of notification to submit the following information
to the Administrator:
(a) The information listed in
subsection (1) of this rule; if applicable, copies
of all medical audit summaries and peer review reports,
that are related to this dispute, from the insurance
carrier, auditing company, etc.;
(b) response to the requestor's
position regarding the dispute;
(c) a summary of the Respondent's
position regarding the dispute; and,
(d) the date of the response.
(4) The Medical Cost Containment
Division may request additional information from either
party to review the medical issues in the dispute. Requested
information should be forwarded to the Division of Medical
Review at the commission within 10 days of receipt of
request.
(5) The Medical Cost Containment
Division shall proceed with the review after all required
and requested information has been received.
(6) Upon completion of the review,
the decision of the Medical Cost Containment Division
will be forwarded to the disputing parties, the employee
and the employee's representative.
(7) Any party feeling aggrieved
by the order of the Administrator shall have 10 days
from the date of notification to appeal the ruling to
an Administrative Law Judge of the Arkansas Workers'
Compensation Commission. Notice of appeal shall be filed
with the Deputy Executive Director of the Arkansas Workers'
Compensation Commission. The notice of appeal shall
contain the following:
(a) a copy of the Administrative
Order appealed from; and
(b) copies of all materials submitted
to the Medical Cost Containment Administrator.
(8) The appealing party shall mail
a copy of all materials which are filed in the appeal
to each opposing party. No response to the appeal of
the Administrator's order is required. A decision must
be entered by the Administrator before any appeal may
be brought.
IV. OTHER SERVICES
A. Outpatient Services
1. When services are unavailable on
an outpatient basis, the attached schedule is hereby adopted.
2. Unavailability must be determined
based upon the Commission's traditional reasonableness standard.
B. Pharmacy Services
1. Pharmaceutical services rendered
as part of inpatient care are considered inclusive within
the inpatient fee schedule and will not be reimbursed separately.
2. All retail pharmaceutical services
rendered will be reimbursed in accordance with the Pharmacy
Schedule.
C. Professional Services
1. All non-institutional professional
services will be reimbursed in accordance with the Arkansas
Workers' Compensation Medical Fee Schedule.
D. Outpatient Schedule
| OHS CPT-CODE* |
DESCRIPTION |
TOTAL |
| 70140 |
RADIOLOGIC EXAMINATION, FACIAL BONES; LESS
THAN THREE VIEWS |
60.00 |
| 70150 |
RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE,
MINIMUM OF THREE VIEWS |
72.50 |
| 70160 |
RADIOLOGIC EXAMINATION, NASAL BONES; COMPLETE,
MINIMUM OF THREE VIEWS |
73.00 |
| 70210 |
RADIOLOGIC EXAMINATION, SINUSES, PARANASAL,
LESS THAN THREE VIEWS |
50.00 |
| 70220 |
RADIOLOGIC EXAMINATION, SINUSES, PARANASAL,
COMPLETE, MINIMUM OF THREE VIEWS |
73.00 |
| 70250 |
RADIOLOGIC EXAMINATION, SKULL; LESS THAN
FOUR VIEWS, WITH OR W/O STEREO |
60.50 |
| 70260 |
RADIOLOGIC EXAMINATION, SKULL, COMPLETE,
MINIMUM OF FOUR VIEWS, WITH OR W/O STEREO |
86.00 |
| 70450 |
COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR
BRAIN; W/O CONTRAST MATERIAL |
458.00 |
| 70460 |
COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR
BRAIN; WITH CONTRAST MATERIAL |
600.00 |
| 70470 |
COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR
BRAIN; W/O CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL
AND FURTHER SECTIONS |
613.00 |
| 70551 |
MAGNETIC RESONANCE (EG, PROTON) IMAGING,
BRAIN (INCLUDING BRAIN STEM);W/O CONTRAST MATERIAL |
826.00 |
| 71010 |
RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW,
FRONTAL |
58.50 |
| 71020 |
RADIOLOGIC EXAMINATION, CHEST; TWO VIEWS,
FRONTAL AND LATERAL |
74.00 |
| 71100 |
RADIOLOGIC EXAMINATION, RIBS, UNILATERAL;
TWO VIEWS |
67.00 |
| 71101 |
RADIOLOGIC EXAMINATION, RIBS, UNILATERAL;
INCLUDING POSTEROANTERIOR CHEST, MINIMUM OF THREE VIEWS |
75.00 |
| 71110 |
RADIOLOGIC EXAMINATION, RIBS, BILATERAL;
THREE VIEWS |
85.00 |
| 71250 |
COMPUTERIZED AXIAL TOMOGRAPHY, THORAX;
W/O CONTRAST MATERIAL |
630.00 |
| 71260 |
COMPUTERIZED AXIAL TOMOGRAPHY, THORAX;
WITH CONTRAST MATERIAL(S) |
672.00 |
| 71270 |
COMPUTERIZED AXIAL TOMOGRAPHY, THORAX;
W/O CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL AND
FURTHER SECTIONS |
735.00 |
| 72010 |
RADIOLOGIC EXAMINATION, SPINE, ENTIRE,
SURVEY STUDY, ANTEROPOSTERIOR AND LATERAL |
128.50 |
| 72040 |
RADIOLOGIC EXAMINATION SPINE, CERVICAL;
ANTEROPOSTERIOR AND LATERAL |
64.00 |
| 72050 |
RADIOLOGIC EXAMINATION, SPINE, CERVICAL;
MINIMUM OF FOUR VIEWS |
104.00 |
| 72052 |
RADIOLOGIC EXAMINATION, SPINE, CERVICAL;
COMPLETE, INCLUDING OBLIQUE AND FLEXION AND/OR EXTENSION
STUDIES |
129.00 |
| 72070 |
RADIOLOGIC EXAMINATION, SPINE; THORACIC,
ANTEROPOSTERIOR AND LATERAL |
83.50 |
| 72100 |
RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL;
ANTEROPOSTERIOR AND LATERAL |
83.00 |
| 72110 |
RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL;
COMPLETE, W/OBLIQUE VIEWS |
119.00 |
| 72125 |
COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL
SPINE; W/O CONTRAST MATERIAL |
431.00 |
| 72126 |
COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL
SPINE; WITH CONTRAST MATERIAL |
489.00 |
| 72127 |
COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL
SPINE; W/O CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S)
AND FURTHER SECTIONS |
567.00 |
| 72128 |
COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC
SPINE; W/O CONTRAST MATERIAL |
431.00 |
| 72129 |
COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC
SPINE; WITH CONTRAST MATERIAL |
494.00 |
| 72130 |
COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC
SPINE; W/O CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S)
AND FURTHER SECTIONS |
567.00 |
| 72131 |
COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE;
W/O CONTRAST MATERIAL |
431.00 |
| 72132 |
COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE;
WITH CONTRAST MATERIAL |
489.00 |
| 72133 |
COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE;
W/O CONTRAST MATERIAL,FOLLOWED BY CONTRAST MATERIAL(S) AND
FURTHER SECTIONS |
562.50 |
| 72141 |
MAGNETIC RESONANCE (EG, PROTON) IMAGING,
SPINAL CANAL AND CONTENTS, CERVICAL; W/O CONTRAST MATERIAL
|
901.00 |
| 72146 |
MAGNETIC RESONANCE (EG, PROTON) IMAGING,
SPINAL CANAL AND CONTENTS, THORACIC; W/O CONTRAST MATERIAL |
945.00 |
| 72147 |
MAGNETIC RESONANCE (EG, PROTON) IMAGING,
SPINAL CANAL AND CONTENTS, THORACIC; WITH CONTRAST MATERIAL
|
1,024.00 |
| 72148 |
MAGNETIC RESONANCE (EG, PROTON) IMAGING,
SPINAL CANAL AND CONTENTS, LUMBAR; W/O CONTRAST MATERIAL |
901.00 |
| 72149 |
MAGNETIC RESONANCE (EG, PROTON) IMAGING,
SPINAL CANAL AND CONTENTS LUMBAR; WITH CONTRAST MATERIAL |
976.50 |
| 72170 |
RADIOLOGIC EXAMINATION, PELVIS; ANTEROPOSTERIOR
ONLY |
65.00 |
| 72190 |
RADIOLOGIC EXAMINATION, PELVIS; COMPLETE,
MINIMUM OF THREE VIEWS |
80.00 |
| 73000 |
RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE |
50.00 |
| 73010 |
RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE |
55.00 |
| 73020 |
RADIOLOGIC EXAMINATION, SHOULDER; ONE VIEW |
51.50 |
| 73030 |
RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE,
MINIMUM OF TWO VIEWS |
75.50 |
| 73060 |
RADIOLOGIC EXAMINATION, HUMERUS, MINIMUM
OF TWO VIEWS |
66.50 |
| 73070 |
RADIOLOGIC EXAMINATION, ELBOW; ANTEROPOSTERIOR
AND LATERAL VIEWS |
66.50 |
| 73080 |
RADIOLOGIC EXAMINATION, ELBOW; COMPLETE,
MINIMUM OF THREE VIEWS |
68.50 |
| 73090 |
RADIOLOGIC EXAMINATION; FOREARM, ANTEROPOSTERIOR
AND LATERAL VIEWS |
66.50 |
| 73100 |
RADIOLOGIC EXAMINATION, WRIST; ANTEROPOSTERIOR
AND LATERAL VIEWS |
66.50 |
| 73110 |
RADIOLOGIC EXAMINATION, WRIST; COMPLETE,
MINIMUM OF THREE VIEWS |
67.00 |
| 73120 |
RADIOLOGIC EXAMINATION, HAND; TWO VIEWS |
57.00 |
| 73130 |
RADIOLOGIC EXAMINATION, HAND; MINIMUM OF
THREE VIEWS |
76.00 |
| 73140 |
RADIOLOGIC EXAMINATION, FINGER OR FINGERS,
MINIMUM OF TWO VIEWS |
55.50 |
| 73500 |
RADIOLOGIC EXAMINATION, HIP; UNILATERAL,
ONE VIEW |
68.50 |
| 73510 |
RADIOLOGIC EXAMINATION, HIP; COMPLETE,
MINIMUM OF TWO VIEWS |
73.00 |
| 73550 |
RADIOLOGIC EXAMINATION, FEMUR; ANTEROPOSTERIOR
AND LATERAL VIEWS |
70.50 |
| 73560 |
RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR
AND LATERAL VIEWS |
63.50 |
| 73562 |
RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR
AND LATERAL, WITH OBLIQUE(S), MINIMUM OF THREE VIEWS |
85.00 |
| 73564 |
RADIOLOGIC EXAMINATION, KNEE; COMPLETE,
INCLUDING OBLIQUE, AND TUNNEL, AND/OR PATELLAR AND/OR STANDING
VIEW |
99.50 |
| 73590 |
RADIOLOGIC EXAMINATION; TIBIA AND FIBULA,
ANTEROPOSTERIOR AND LATERAL VIEWS |
74.50 |
| 73600 |
RADIOLOGIC EXAMINATION, ANKLE; ANTEROPOSTERIOR
AND LATERAL VIEWS |
61.50 |
| 73610 |
RADIOLOGIC EXAMINATION, ANKLE; COMPLETE,
MINIMUM OF THREE VIEWS |
62.50 |
| 73620 |
RADIOLOGIC EXAMINATION, FOOT; ANTEROPOSTERIOR
AND LATERAL VIEWS |
60.00 |
| 73630 |
RADIOLOGIC EXAMINATION, FOOT; COMPLETE,
MINIMUM OF THREE VIEWS |
52.00 |
| 73650 |
RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM
OF TWO VIEWS |
62.00 |
| 73660 |
RADIOLOGIC EXAMINATION; TOE OR TOES, MINIMUM
OF TWO VIEWS |
63.00 |
| 73720 |
MAGNETIC RESONANCE (EG, PROTON) IMAGING,
LOWER EXTREMITY, OTHER THAN JOINT |
901.00 |
| 74000 |
RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE
ANTEROPOSTERIOR VIEW |
72.00 |
| 74010 |
RADIOLOGIC EXAMINATION, ABDOMEN; ANTEROPOSTERIOR
AND ADDITIONAL OBLIQUE AND CONE VIEWS |
80.00 |
| 74020 |
RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE,
INCLUDING DECUBITUS AND/OR ERECT VIEWS |
95.00 |
| 74022 |
RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE
ACUTE ABDOMEN SERIES, INCLUDING SUPINE, ERECT, AND/OR DECUBITUS
VIEWS, UPRIGHT PA CHEST |
102.50 |
| 74150 |
COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN;
W/O CONTRAST MATERIAL |
630.00 |
| 74160 |
COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN;
WITH CONTRAST MATERIAL(S) |
651.50 |
| 74170 |
COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN;
W/O CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND
FURTHER SECTIONS |
726.50 |
| 74220 |
RADIOLOGIC EXAMINATION; ESOPHAGUS |
100.00 |
| 74230 |
SWALLOWING FUNCTION, PHARYNX AND/OR ESOPHAGUS,
WITH CINERADIOGRAPHY AND/OR VIDEO |
100.00 |
| 74240 |
RADIOLOGIC EXAMINATION, GASTROINTESTINAL
TRACT, UPPER; WITH OR WITHOUT DELAYED FILMS, W/O KUB |
131.00 |
| 74241 |
RADIOLOGIC EXAMINATION, GASTROINTESTINAL
TRACT, UPPER; WITH OR WITHOUT DELAYED FILMS, WITH KUB
|
131.00 |
| 74245 |
RADIOLOGIC EXAMINATION, GASTROINTESTINAL
TRACT, UPPER; WITH SMALL BOWEL, INCLUDES MULTIPLE SERIAL
FILMS |
142.00 |
| 74246 |
RADIOLOGIC EXAMINATION, GASTROINTESTINAL
TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM,
EFFERVESCENT AGENT, WITH OR WITHOUT GLUCAGON; WITH OR WITHOUT
DELAYED FILMS, W/O KUB |
142.00 |
| 74247 |
RADIOLOGIC EXAMINATION, GASTROINTESTINAL
TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM,
EFFERVESCENT AGENT, WITH OR WITHOUT GLUCAGON; WITH OR WITHOUT
DELAYED FILMS, WITH KUB |
142.00 |
| 74250 |
RADIOLOGIC EXAMINATION, SMALL BOWEL, INCLUDES
MULTIPLE SERIAL FILMS |
101.00 |
| 74270 |
RADIOLOGIC EXAMINATION, COLON; BARIUM ENEMA |
129.00 |
| 74280 |
RADIOLOGIC EXAMINATION, COLON; AIR CONTRAST
WITH SPECIFIC HIGH DENSITY BARIUM, WITH OR W/O GLUCAGON
|
147.00 |
| 74290 |
CHOLECYSTOGRAPHY, ORAL CONTRAST |
100.00 |
| 74400 |
UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, WITH
OR W/O KUB, WITH OR W/O TOMOGRAPHY |
158.00 |
| 74415 |
UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR
BOLUS TECHNIQUE; WITH NEPHROTOMOGRAPHY |
210.00 |
| 76090 |
MAMMOGRAPHY; UNILATERAL |
61.50 |
| 76091 |
MAMMOGRAPHY; BILATERAL |
75.00 |
| 76092 |
SCREENING MAMMOGRAPHY, BILATERAL (TWO VIEW
FILM STUDY OF EACH BREAST) |
60.00 |
| 76100 |
RADIOLOGIC EXAMINATION, SINGLE PLANE BODY
SECTION, (EG, TOMOGRAPHY), OTHER THAN WITH UROGRAPHY |
131.00 |
| 76536 |
ECHOGRAPHY, SOFT TISSUES OF HEAD AND NECK
(EG, THYROID, PARATHYROID, PAROTID), B-SCAN AND/OR REAL
TIME W/IMAGE DOCUMENTATION |
168.00 |
| 76645 |
ECHOGRAPHY, BREAST(S) (UNILATERAL OR BILATERAL),
B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION |
65.00 |
| 76700 |
ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR REAL
TIME W/IMAGE DOCUMENTATION; COMPLETE |
200.00 |
| 76705 |
ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR REAL
TIME W/IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN,
QUADRANT, FOLLOW-UP) |
126.00 |
| 76770 |
ECHOGRAPHY, RETROPERITONEAL (EG, RENAL,
AORTA, NODES), B-SCAN AND/OR REALTIME WITH IMAGE DOCUMENTATION;
COMPLETE |
158.00 |
| 76805 |
ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR
REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE (COMPLETE FETAL
AND MATERNAL EVALUATION) |
168.00 |
| 76815 |
ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR
REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (GESTATIONAL
AGE, HEARTBEAT, PLACENTAL LOCATION, FETAL POSITION, OR EMERGENCY
IN THE DELIVERY ROOM) |
105.00 |
| 76816 |
ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR
REAL TIME WITH IMAGE DOCUMENTATION; FOLLOW-UP OR REPEAT |
105.00 |
| 76856 |
ECHOGRAPHY, PELVIC (NONOBSTETRIC), B-SCAN
AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE |
158.00 |
| 80061 |
LIPID PANEL |
69.00 |
| 81000 |
URINALYSIS |
14.00 |
| 81002 |
URINALYSIS, W/O MICROSCOPY |
14.00 |
| 81015 |
URINALYSIS, MICROSCOPIC ONLY |
10.00 |
| 82150 |
AMYLASE |
31.00 |
| 82270 |
BLOOD, OCCULT; FECES SCREENING |
19.00 |
| 82310 |
CALCIUM, BLOOD; CHEMICAL |
21.00 |
| 82374 |
CARBON DIOXIDE (BICARBONATE), COMBINING
POWER OR CONTENT |
22.00 |
| 82435 |
CHLORIDE; BLOOD (SPECIFY CHEMICAL OR ELECTROMETRIC) |
22.00 |
| 82465 |
CHOLESTEROL, SERUM, TOTAL |
20.00 |
| 82550 |
CREATINE PHOSPHOKINASE (CPK), TIMED KINETIC
ULTRAVIOLET METHOD |
13.00 |
| 82552 |
CREATINE PHOSPHOKINASE (CPK), ISOENZYMES |
52.00 |
| 82565 |
CREATINE |
22.00 |
| 82660 |
DRUG SCREEN (AMPHETAMINES, BARBITURATES,
ALKALOIDS) (82660 HAS BEEN DELETED. (TO REPORT, SEE 80100,
80101) |
76.50 |
| 82803 |
GASES, pH, pCO2,
p02 SIMULTANEOUS |
73.00 |
| 82947 |
GLUCOSE; EXCEPT URINE |
19.50 |
| 82948 |
GLUCOSE; STICK TEST |
11.00 |
| 83615 |
LACTIC DEHYDROGENASE (LDH), KINETIC ULTRAVIOLET
METHOD |
22.00 |
| 83705 |
LIPIDS, FRACTIONATED (83705 HAS BEEN DELETED.
TO REPORT CHOLESTEROL, SEE 82465, 83718-83721. FOR TRIGLYCERIDES,
SEE 84478) |
58.00 |
| 83718 |
LIPOPROTEIN HIGH DENSITY CHOLESTEROL BY
PRECIPITATION METHOD |
40.00 |
| 84075 |
PHOSPHATASE, ALKALINE |
26.00 |
| 84132 |
POTASSIUM; SERUM |
23.00 |
| 84155 |
PROTEIN; TOTAL, EXCEPT REFRACTOMETRY |
16.00 |
| 84165 |
PROTEIN, TOTAL, SERUM; ELECTROPHORETIC
FRACTIONATION AND QUANTITATION |
31.00 |
| 84295 |
SODIUM; SERUM |
26.00 |
| 84436 |
THYROXINE, TRUE (TT-4), RIA |
37.00 |
| 84439 |
THYROXINE, FREE (FT-4), RIA (UNBOUND T-4
ONLY) |
37.00 |
| 84443 |
THYROID STIMULATING HORMONE |
56.00 |
| 84450 |
TRANSAMINASE, GLUTAMIC OXALOACETIC, (SGOT),
BLOOD; TIMED KINETIC ULTRAVIOLET METHOD |
22.00 |
| 84460 |
TRANSAMINASE, GLUTAMIC PYRUVIC (SGPT),
BLOOD; TIMED KINETIC ULTRAVIOLET METHOD |
18.00 |
| 84478 |
TRIGLYCERIDES, BLOOD |
24.00 |
| 84479 |
TRIDOTHYRONINE (T-3), RESIN UPTAKE |
26.00 |
| 84480 |
TRIDOTHYRONINE, TOTAL (TT-3) |
48.00 |
| 84520 |
UREA NITROGEN, (BUN); QUANTITATIVE |
19.00 |
| 84525 |
UREA NITROGEN, (BUN); SEMIQUANTITATIVE
(EG, REAGENT STRIP TEST) |
21.00 |
| 84550 |
URIC ACID; BLOOD, CHEMICAL |
22.00 |
| 84702 |
GONADOTROPIN, CHORIONIC; QUANTITATIVE |
34.00 |
| 84703 |
GONADOTROPIN, CHORIONIC; QUALITATIVE |
36.00 |
| 85002 |
BLEEDING TIME |
19.50 |
| 85007 |
BLOOD COUNT; MANUAL DIFFERENTIAL WBC COUNT |
12.00 |
| 85009 |
BLOOD COUNT; DIFFERENTIAL WBC COUNT, BUFFY
COAT |
16.00 |
| 85014 |
BLOOD COUNT; HEMATOCRIT |
16.00 |
| 85018 |
BLOOD COUNT; HEMOGLOBIN, COLORIMETRIC |
16.00 |
| 85025 |
BLOOD COUNT; HEMOGRAM AND PLATELET COUNT,
AUTOMATED AND AUTOMATED COMPLETE DIFFERENTIAL WBC
COUNT |
26.00 |
| 85027 |
BLOOD COUNT; HEMOGRAM AND PLATELET COUNT,
AUTOMATED |
26.00 |
| 85048 |
BLOOD COUNT; WHITE BLOOD CELL (WBC) |
16.00 |
| 85610 |
PROTHROMBIN TIME |
19.00 |
| 85651 |
SEDIMENTATION RATE (ESR); NON-AUTOMATED
|
19.00 |
| 85730 |
THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA
OR WHOLE BLOOD |
32.00 |
| 85732 |
THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTITION,
PLASMA |
23.00 |
| 86300 |
HETEROPHILE ANTIBODIES; SCREENING, SLIDE
OR TUBE (86300 HAS BEEN DELETED. (TO REPORT, SEE 86308) |
23.00 |
| 86430 |
RHEUMATOID FACTOR; QUALITATIVE |
21.00 |
| 87040 |
CULTURE, BACTERIAL, DEFINITIVE; BLOOD |
47.00 |
| 87045 |
CULTURE, BACTERIAL, DEFINITIVE, STOOL |
47.00 |
| 87070 |
CULTURE, BACTERIAL, DEFINITIVE, ANY OTHER
SOURCE |
43.50 |
| 87075 |
CULTURE, BACTERIAL, ANY SOURCE; ANAEROBIC |
47.00 |
| 87081 |
CULTURE, BACTERIAL, SCREENING ONLY, FOR
SINGLE ORGANISMS |
21.00 |
| 87086 |
CULTURE, BACTERIAL, URINE; QUANTITATIVE,
COLONY COUNT |
47.00 |
| 87177 |
OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION
AND IDENTIFICATION |
33.00 |
| 87205 |
SMEAR, PRIMARY SOURCE, WITH INTERPRETATION;
ROUTINE STAIN FOR BACTERIA, FUNGI, OR CELL TYPES |
18.00 |
| 87210 |
SMEAR, PRIMARY SOURCE, WITH INTERPRETATION;
WET MOUNT WITH SIMPLE STAIN FOR BACTERIA, FUNGI, OVA, AND/OR
PARASITES |
21.00 |
| 88150 |
CYTOPATHOLOGY, SMEARS, CERVICAL OR VAGINAL,
UP TO THREE SMEARS; SCREENING BYTECHNICIAN UNDER PHYSICIAN
SUPERVISION |
16.00 |
| |
PROCEDURE DESCRIPTION |
| 92585 |
BRAINSTEM EVOKED RESPONSE RECORDING
(EVOKED RESPONSE [EEG] AUDIOMETRY) |
| 93017 |
CARDIOVASCULAR STRESS TESTING
WITH MAXIMAL OR SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE |
| 93018 |
INTERPRETATION AND REPORT ONLY |
| 93041 |
RHYTHM ECG, ONE TO THREE LEADS;
TRACING ONLY W/O I & R |
| 93224 |
ELECTROCARDIOGRAPHIC MONITORING
FOR 24 HRS. BY CONTINUOUS ORIGINAL ECG WAVEFORM, ETC. |
| 93227 |
ELECTROCARDIOGRAPHIC MONITORING
FOR 24 HRS. BY CONTINUOUS ORIGINAL ECG WAVEFORM, ETC. |
| 93235 |
ELECTROCARDIOGRAPHIC MONITORING
FOR 24 HRS. BY CONTINUOUS COMPUTERIZED MONITORING, ETC. |
| 93278 |
SIGNAL-AVERAGED ELECTROCARDIOGRAPHY
(SAECG) WITH OR W/O ECG |
| 93307 |
ECHOCARDIOGRAPHY, REAL-TIME
WITH IMAGE DOCUMENTATION (2D) WITH OR W/O M-MODE |
| 93308 |
ECHOCARDIOGRAPHY, REAL-TIME
WITH IMAGE DOCUMENTATION (2D) WITH OR W/O M-MODE |
| 93320 |
DOPPLER ECHOCARDIOGRAPHY, PULSED
WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPL |
| 93880 |
DUPLEX SCAN OF EXTRACRANIAL
ARTERIES; COMPLETE BILATERAL STUDY |
| 93882 |
DUPLEX SCAN OF EXTRACRANIAL
ARTERIES; FOLLOW-UP OR LIMITED STUDY |
| 93886 |
TRANSCRANIAL DOPPLER STUDY
OF THE INTERCRANIAL ARTERIES; COMPLETE |
| 93888 |
TRANSCRANIAL DOPPLER STUDY
OF THE INTERCRANIAL ARTERIES; FOLLOW-UP |
| 93890 |
NON-INVASIVE STUDIES OF UPPER
EXTREMITY ARTERIES (EG SEGMENTAL BLOOD) - (93890 HAS BEEN
DELETED; TO REPORT, PLEASE SEE 93920, 93931) |
| 93925 |
DUPLEX SCAN OF LOWER EXTREMITY
ARTERIES OR ARTERIAL BYPASS GRAFTS; COM |
| 93926 |
DUPLEX SCAN OF LOWER EXTREMITY
ARTERIES OR ARTERIAL BYPASS GRAFTS; FOL |
| 93930 |
DUPLEX SCAN OF UPPER EXTREMITY
ARTERIES OR ARTERIAL BYPASS GRAFTS; COM |
| 93931 |
DUPLEX SCAN OF UPPER EXTREMITY
ARTERIES OR ARTERIAL BYPASS GRAFTS; FOL |
| 93965 |
NON-INVASIVE PHYSIOLOGIC STUDIES
OF EXTREMITY VEINS, BILATERAL, (EG, |
| 93970 |
DUPLEX SCAN OF EXTREMITY VEINS
INCLUDING RESPONSES TO COMPRESSION AND |
| 93971 |
DUPLEX SCAN OF EXTREMITY VEINS
INCLUDING RESPONSES TO COMPRESSION AND |
| 93975 |
DUPLEX SCAN OF ARTERIAL INFLOW
AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC |
| 93976 |
DUPLEX SCAN OF ARTERIAL INFLOW
AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC |
| 93978 |
DUPLEX SCAN OF AORTA, INFERIOR
VENA CAVA ILIAC VASCULATURE, OR BYPASS |
| 93979 |
DUPLEX SCAN OF AORTA, INFERIOR
VENA CAVA ILIAC VASCULATURE, OR BYPASS |
| 95863 |
ELECTROMYOGRAPHY; TWO EXTREMITIES
AND RELATED PARASPINAL AREAS |
| 95864 |
ELECTROMYOGRAPHY; FOUR EXTREMITIES
AND RELATED PARASPINAL AREAS |
| 95867 |
ELECTROMYOGRAPHY; CARNIAL NERVE-SUPPLIED
MUSCLES; UNILATERAL |
| 95868 |
ELECTROMYOGRAPHY; CARNIAL NERVE-SUPPLIED
MUSCLES; BILATERAL |
| 95925 |
SOMOTOSENSORY TESTING (E.G.
CEREBRAL EVOKED POTENTIAL) 1 OR MORE NERVE |
| 95950 |
MONITORING FOR IDENTIFICATION
AND LATERALIZATION OF CEREBRAL SEIZURE |
| 97010 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; HOT OR COLD PACKS |
| 97012 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; TRACTION, MECHANICAL |
| 97014 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; ELECTRICAL STIMULATION |
| 97016 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; VASOPNEUMATIC DEVICES |
| 97018 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; PARAFFIN BATH |
| 97022 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; WHIRLPOOL |
| 97024 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; DIATHERMY |
| 97026 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; INFRARED |
| 97028 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; ULTRAVIOLET |
| 97039 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA; UNLISTED MODALITY (SPECIFY) |
| 97110 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA, INITIAL 30 MINUTES, EA. VISIT |
| 97112 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA, INITIAL 30 MINUTES, EA. VISIT |
| 97116 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA, INITIAL 30 MINUTES, EA. VISIT |
| 97124 |
PHYSICAL MEDICINE TREATMENT
TO ONE AREA, INITIAL 30 MINUTES, EA. VISIT |
| 97530 |
KINETIC ACTIVITIES TO INCREASE
COORDINATION, STRENGTH AND/OR RANGE OF |
| 97799 |
UNLISTED PHYSICAL MEDICINE
SERVICE OR PROCEDURE |
NOTE: SEE "PHYSICIANS' CURRENT PROCEDURAL
TERMINOLOGY" (CPT) CODE BOOK FOR COMPLETE PROCEDURE DESCRIPTION
ALL OTHER PROCEDURES NOT LISTED IN
THIS SCHEDULE SHALL BE PAID AT THE
HOSPITAL'S USUAL AND CUSTOMARY OR NORMAL BILLED CHARGE AMOUNTS.
*CPT codes and descriptions only are copyright
© 1993 American Medical Association.
Workers' compensation payments for the above
procedures shall be paid at the hospital's usual and customary
or normal billed charge amount less 5%.
State of Arkansas
Workers' Compensation Commission
324 Spring Street
P.O. Box 950
Little Rock, Arkansas 72203-0950
Telephone 1-501-682-3930 / 1-800-622-4472
Legal Advisor Direct 1-800-250-2511
Arkansas Relay System TDD 1-800-285-1131
For
information or comments regarding this site
contact the AWCC Communications Liaison
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