For Services Rendered
Arkansas Workers' Compensation Laws
The official Medical Fee Schedule
of the Arkansas Workers' Compensation Commission shall be based
upon the Health Care Financing Administrations's (HCFA) Medicare
Resource Based Relative Value Scale (RBRVS), utilizing HCFA's
national relative value units and Arkansas specific conversion
factors adopted by the AWCC. Parties using this schedule should
also be familiar with Commission Rule 30, the most
current CPT, the Health Care Financing Administration
Common Procedure Coding System (HCPCS), and the ASA Relative
I. EFFECTIVE DATE AND CODING REFERENCES
This fee schedule shall replace the current
AWCC fee schedule on May 15, 2000 and the most current versions
of CPT and the Medicare RBRVS shall automatically be
applicable upon their effective dates.
II. GENERAL INFORMATION and INSTRUCTIONS
This schedule consists of the following
sections: Medicine (including Evaluation and Management
Services), Surgery, Radiology, Pathology, Anesthesiology, Injections,
Durable Medical Equipment, Orthotics, Pharmacy, and Hospital.
Providers are to use the section(s) which contain the procedure(s)
they perform, or the service(s) they render. Each section has
specific instructions or Guidelines. (See Guidelines).
Reimbursement to providers shall be the
lesser of the following:
1. The provider's usual charge
2. The fee calculated according to the
AWCC Official Fee Schedule
3. The MCO/PPO contracted price
C. FEE SCHEDULE CALCULATION
The AWCC Official Fee Schedule can be calculated
for any specific CPT code by multiplying the national "fully implemented non-facility total relative value units" (RVUs) by the conversion
factor applicable to that CPT.
D. CONVERSION FACTORS
The conversion factors applicable to this
Fee Schedule are as follows:
Radiology ............................................................................. $70.00
Medicine (includes Evaluation and
Management Services)................................................................................ $44.28
Pathology codes that do not have
RVUs listed in the Medicare RBRVS should be reimbursed 200%
of Arkansas Medicare for Clinical Diagnostic Laboratory Fee
Schedule allowance, with 30% for the Professional Component
and 70% for the Technical Component.
The following forms (or their replacements)
should be used for provider billing:
Bills for reimbursement should be sent directly
to the party responsible for reimbursement. In most instances,
this is the Insurance Carrier or the Self-Insured Employer.
Providers should be able to obtain this information from the
Guidelines define items that are necessary
to appropriately interpret and report the procedures and services
contained in a particular section and provide explanations regarding
terms that apply only to a particular section.
The Guidelines found in the most current
CPT apply to the following: Evaluation and Management,
Medicine, Surgery, Radiology, and Pathology.
In addition to the Guidelines found in the
CPT, the following AWCC Guidelines also apply:
1. Multiple Procedures: Reimbursement
shall be based on 100% of the physician's usual charge for
the major procedure (not to exceed 100% of the Medical Fee
Schedule allowable) plus 50% of the physician's usual charge
for the lesser or secondary procedure (s) (not to exceed 50%
of the Medical Fee Schedule allowable).
2. Services Rendered by More Than
a. Concurrent Care: See
Evaluation and Management (E/M) Services Guidelines.
b. Surgical Assistant: Only
a physician who assists at surgery may be reimbursed as
a surgical assistant. To identify surgical assistant services,
Modifier 80 or 81 should be added to the surgical procedure
code which is billed. A surgical assistant must submit a
copy of the operative report to substantiate the services
rendered. Reimbursement is limited to the lesser of the
surgical assistant's usual charge or 20% of the maximum
allowable Fee Schedule amount.
c. Two Surgeons: For
reporting see the most current CPT. Each
surgeon must submit an operative report documenting the
specific surgical procedure(s) provided. Each surgeon must
submit an individual bill for the services rendered. Reimbursement
must not be made to either surgeon until the carrier has
received each surgeon's individual operative report and
bill. Reimbursement to each surgeon must be made at the
provider's usual charge or the maximum allowable Fee Schedule
amount, whichever is less.
1. General Information and Instructions.
ASA Relative Value Guide, by the American Society
of Anesthesiologists will be used to determine reimbursement
for codes that do not appear in the RBRVS.
These values are to be used only when the anesthesia is personally
administered by an Anesthesiologist or Certified Registered
Nurse Anesthetist (CRNA) who remains in constant attendance
during the procedure, for the sole purpose of rendering such
To order the Relative Value
Guide, write to the American Society of Anesthesiologists;
520 N Northwest Highway; Park Ridge, IL 60068-2573 or call
When anesthesia is administered by a CRNA
not under the medical direction of an anesthesiologist, reimbursement
shall be 90% of the provider's usual charge or the ARA, which
ever is less. No payment will be made to the surgeon supervising
When anesthesia is administered personally
by an anesthesiologist or administered by a care team involving
an anesthesiologist and CRNA, reimbursement shall not exceed
100% of the provider's usual charge or the ARA, whichever
2. Anesthesia Values
Each anesthesia service contains two value
components which make up the charge and determine reimbursement:
a Basic Value and a Time Value.
a. Basic Value relates
to the complexity of the service and includes the value
of all usual anesthesia services except the time actually
spent in anesthesia care and any modifiers. The Basic
Value includes usual preoperative and postoperative
visits, the anesthesia care during the procedure, the administration
of fluids and/or blood products incidental to the anesthesia
or surgery and interpretation of non-invasive monitoring
(ECG, temperature, blood pressure, oximetry, capnography,
and mass spectrometry). When multiple surgical procedures
are performed during an operative session, the Basic
Value for anesthesia is the Basic Value
for the procedure with the highest unit value. The Basic
Values in units for each anesthesia procedure code
are listed in the current ASA Relative Value
b. Time Value
Anesthesia time starts when the anesthesiologist
or CRNA begins to prepare the patient for induction of anesthesia
and ends when the personal attendance of the anesthesiologist
or CRNA is no longer required and the patient can be safely
placed under customary, postoperative supervision. Anesthesia
time must be reported on the claim form as the total number
of minutes of anesthesia. For example,
one hour and eleven minutes equals 71 minutes of anesthesia.
The Time Value is converted into units
for reimbursement as follows:
Each 15 minutes or any fraction thereof
equals one (1) time unit.
Example: 71 minutes of anesthesia time
would have the following time units: 71/15 = 5 Time Units.
No additional time units are allowed
for recovery room observation monitoring after the patient
can be safely placed under customary postoperative supervision.
3. Total Anesthesia Value
The total anesthesia value (TAV)
for an anesthesia service is the sum of the Basic
Value (units) plus the Time Value which has been converted
into units. The TAV is calculated for the purpose of determining
Anesthesia services must be reported by
entering the appropriate anesthesia procedure code and descriptor
into Element 24 D of the HCFA 1500 Form. The provider's usual
total charge for the anesthesia service must be entered in
Element 24 F on the HCFA 1500 Form. The total time in minutes
must be entered in Element 24 G of the HCFA 1500 Form.
Reimbursement for anesthesia services
must be made at the provider's usual charge or the Anesthesia
Reimbursement Allowance (ARA), whichever is less.
The ARA is calculated by determining the total anesthesia
value for the service rendered and then multiplying that value
by an established conversion factor which has a dollar value.
Total Anesthesia Value (Basic
Value + Time Value +
Physical Status Modifiers when applicable)
X Conversion Factor = ARA
The conversion factor for Arkansas Workers'
Compensation is $41.76.
6. Methodology for Calculating
a. Refer to the Anesthesia Codes in
the Relative Value Guide to locate
the applicable anesthesia procedure code and corresponding
b. Determine Time Units.
c. Any minutes which exceed the whole
units are counted as whole units.
d. Add Basic Value and Time Units to
determine Total Anesthesia Value (TAV).
e. Multiply TAV by the Conversion Factor,
$41.76, to obtain the ARA.
7. Special Anesthesia Services
a. Unusual Circumstances (Modifiers
22, and 23).
Under certain circumstances, the anesthesia
service(s) provided may vary significantly from those usually
required for the listed procedures. The use of modifiers
is appropriate for these instances. The following are modifiers
which are commonly used in anesthesia services.
b. 22 Unusual Services: When the service(s)
provided is greater than usually required for the listed
procedure, it may be identified by adding modifier 22 to
the usual procedure number or by use of the separate five-digit
modifier code 09922. A report is required.
c. 23 Unusual Anesthesia: Occasionally
a procedure which usually requires either no anesthesia
or local anesthesia, because of unusual circumstances, must
be done under general anesthesia. This circumstance may
be reported by adding the modifier 23 to the procedure code
of the basic service or by use of the separate five digit
modifier code 09923.
d. For additional modifiers for physical
status and qualifying circumstances see the Relative
Value Guide. The use of modifiers does not
guarantee additional reimbursement.
8. Monitored Anesthesia Care
When an anesthesiologist or CRNA is required
to participate in, and be responsible for, monitoring the
general care of the patient during surgery but does not administer
anesthetic, such professional services must be billed and
reimbursed as though an anesthetic were administered; that
is, basic anesthesia plus time.
9. Medical Direction Provided
When an anesthesiologist is not personally
administering the anesthesia but is providing medical direction
for the services of a nurse anesthetist who is not employed
by the anesthesiologist, the anesthesiologist may bill for
the medical direction. Medical direction includes the pre
and postoperative evaluation of the patient. The anesthesiologist
must remain within the operating suite, including the pre-anesthesia
and post-anesthesia recovery areas, except in extreme emergency
situations. Reimbursement for medical direction by anesthesiologists
must be at the provider's usual charge or 50 percent of the
ARA, whichever is less.
10. Anesthesia by Surgeon
a. Local Anesthesia
When infiltration, digital block or
topical anesthesia is administered by the operating surgeon
or surgeon's assistant, reimbursement for the procedure
and anesthesia are included in the global reimbursement
for the procedure.
b. Regional or General Anesthesia
When regional or general anesthesia
is provided by the operating surgeon or surgeon's assistant,
the surgeon may be reimbursed for the anesthesia service
in addition to the surgical procedure.
1) To identify the anesthesia service,
list the CPT surgical procedure code and add Modifier
2) Reimbursement shall be either the
provider's usual charge or the ARA.
The operating surgeon must not
use the diagnostic or therapeutic nerve block codes to
bill for administering regional anesthesia for a surgical
11. Unlisted Service, Procedure
or Unit Value: When an unlisted service or procedure
is provided or without specified unit values, the values used
should be substantiated "BR" (By
12. Procedures Listed In The ASA
Relative Value Guide Without Specified Unit Values: For
any procedure or service that is unlisted or without specified
unit value, the physician or anesthetist shall establish a
unit value consistent in relativity with other unit values
shown in the current ASA Relative
Value Guide. Pertinent
information concerning the nature, extent and need for the
procedure or service, the time, the skill and equipment necessary,
etc., is to be furnished. Sufficient information should be
furnished to identify the problem and the service(s).
13. Actual time of beginning
and duration of anesthesia time may require documentation,
such as a copy of the anesthesia record in the hospital file.
14. Special Supplies:
Supplies and materials provided by the physician over and
above those usually included with the office visit or other
services rendered may be listed separately. List drugs, tray
supplies, and materials provided separately.
Supplies and materials provided in a hospital or other facility
must not be billed separately by the physician or CRNA. These
charges must be billed by the hospital.
15. Separate or Multiple Procedures:
It is appropriate to designate multiple procedures
that are rendered on the same date by separate entries.
General Information and Guidelines
Reimbursement for injection(s) (such as
J codes) includes allowance for CPT code 96372 in addition to
wholesale price of each drug. In cases where multiple drugs
are given as one injection, only one administration fee is owed.
Surgery procedure codes defined as injections
include the administration portion of payment for the medications
J Codes are found in the Health Care Financing
Administration Common Procedure Coding System (HCPCS).
D. DURABLE MEDICAL EQUIPMENT (DME)
Supplies and equipment addressed in this
fee guideline will be reimbursed at a reasonable amount. Supplies
and equipment not addressed in this fee guideline will be reimbursed
at a reasonable amount and coded 99070. All billing must contain
the brand name, model number, and/or catalog number. Codes to
be used are found in the HCPCS.
The reimbursement for supplies/equipment
in this fee guideline is based on a presumption that the injured
worker is being provided the highest quality of supplies/equipment.
All billing must contain the brand name, model number, and/or
catalog number, and a copy of the invoice.
Rental fees are applicable in instances
of short-term utilization (30-60 days). If it is more cost
effective to purchase an item rather than rent it, this must
be stressed and brought to the attention of the insurance
carrier. The first month's rent should apply to the purchase
price. However, if the decision to purchase an item is delayed
by the insurance carrier, subsequent rental fees cannot be
applied to the purchase price. When billing for rental, identify
with modifier "RT".
3. TENs UNITS
All bills submitted to the carrier for
Tens and Cranial Electrical Stimulator (CES) units must be
accompanied by a copy of the invoice.
1) Include the following supplies:
(a) lead wires;
(b) three (3) rechargeable batteries;
(c) battery charger;
(d) electrodes; and
(e) instruction manual and/or audio
2) Supplies submitted for reimbursement
must be itemized. In unusual circumstances where additional
supplies are necessary, use modifier 22 and "BR".
3) Limited to 30 days trial period.
1) Prior to the completion of the 30-day
trial period, the prescribing doctor must submit a report
documenting the medical justification for the continued
use of the unit. The report should identify the following:
(a) Describe the condition and diagnosis
that necessitates the use of a TENs unit.
(b) Does the patient have any other
implants which would affect the performance of the TENs
unit or the implanted unit?
(c) Describe how the TENs unit will
be utilized in the treatment plan.
(d) Who/how was the unit evaluated
for effective pain control during the trial period?
(e) Who/how was the patient instructed
in the use of the unit?
(f) And how often does the patient
use the unit and under which conditions is it used?
2) The purchase price should include:
(a) lead wires;
(b) three (3) rechargeable batteries;
(c) a battery charger.
3) Only the first month's rental price
will be credited to purchase price.
4) Provider will indicate TENs manufacturer,
model name, and serial number as shown on invoice.
5) All TENs units and supplies are listed
in the DME list.
4. CONTINUOUS PASSIVE MOTION (USE
Use of this unit in excess of 30 days
requires documentation of medical necessity by the doctor.
Only one (1) set of soft goods will be allowed for purchase.
E. ORTHOTICS AND PROSTHETICS
Reimbursement for orthotics and prosthetics
shall be based on reasonableness and necessity. Orthotics and
prosthetics should be coded according to the HCFA Common Procedures
Coding System and billed By Report (BR). Copies may be obtained
from the American Orthotic and Prosthetic Association, 1650
King Street, Suite 500, Alexandria, VA 22314, (703) 836-7116.
F. PHARMACY SCHEDULE
The Pharmaceutical Fee Guideline
for prescribed drugs (medicines by pharmacists and dispensing
practitioners) under the Arkansas workers' compensation laws
is the lesser of:
1. The provider's usual charge; or
2. The fees established by the formula
for brand-name and generic pharmaceuticals as described in
subsection (2) of this section.
3. Prescribed Medication Services
a. "Medicine" or "drugs"
shall be defined by Ark. Code Ann. � 17-92-101.
b. Medicine or drugs may only be dispensed
by a currently licensed pharmacist or a dispensing practitioner.
c. For the purposes of this act medicines
are defined as drugs prescribed by an authorized health
care provider and include only generic drugs or single-source
patented drugs for which there is no generic equivalent,
unless the authorized health care provider writes or states
that the brand name is medically necessary and includes
on the prescription "dispense as written" or "DAW."
a. The pharmaceutical reimbursement
formula for prescribed drugs (medicines by pharmacists and
dispensing practitioners) is the lesser of:
Average Wholesale Price (AWP)
+ $5.13 dispensing fee; or the provider's usual charge.
b. Reimbursement to pharmacists must
not exceed the amount calculated by the pharmaceutical reimbursement
formula for prescribed drugs.
c. A bill or receipt for a prescription
drug shall include all of the following:
1) When a brand name drug is dispensed,
the brand name shall be included unless the prescriber
indicates "do not label."
2) If the drug has no brand name,
the generic name, and the manufacturer's name or the supplier's
name, shall be included, unless the prescriber indicates
"do not label."
3) The strength, unless the prescriber
indicates "do not label."
4) The quantity dispensed.
5) The dosage.
6) The name, address, and federal
tax ID# of the pharmacy.
7) The serial number of the prescription,
8) The date dispensed.
9) The name of the prescriber.
10) The name of the patient.
11) The price for which the drug was
sold to the purchaser.
12) The NDC Number (National Drug
d. Determine AWP from the appropriate
monthly publication. The monthly publication that shall
be used for calculation shall be the same as the date of
service. When an AWP is changed during the month, the provider
shall still use the AWP from the monthly publication. The
publications to be used are:
1) Primary reference. PriceAlert
from First DataBank.
2) Secondary reference (for drugs
NOT found in PriceAlert).
Red Book from Medical Economics.
5. "Patent" or "Proprietary
a. "Patent" or "Proprietary
preparations," frequently called "over-the-counter
drugs," are sometimes prescribed for a work-related
injury or illness instead of a legend drug.
b. Generic substitution as discussed
in A.3. above applies also to "over-the-counter"
c. Pharmacists must bill and be reimbursed
their usual and customary charge for the "over-the-counter"
d. The reimbursement formula does not
apply to the "over-the-counter" drugs and no dispensing
fee may be reimbursed.
6. Dispensing Practitioner
a. Dispensing practitioners shall be
reimbursed the same as pharmacists for prescribed drugs
(medicines), except they shall not receive a dispensing
b. "Patent" or "proprietary
preparations" frequently called "over-the-counter
drugs," dispensed by a physician(s) from their office(s)
to a patient during an office visit should be billed as
1) Procedure Code 99070 must be used
to bill for the "proprietary preparation" and
the name of the preparation, dosage and package size must
be listed as the descriptor.
2) An invoice indicating the cost
of the "proprietary preparation" must be submitted
to the carrier with the HCFA 1500 Form.
3) Reimbursement is limited to the
provider's charge or up to 20 percent above the actual
cost of the item.
State of Arkansas
Workers' Compensation Commission
324 South 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
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