Is there a pamphlet with all this information in it? Yes!
For PDF format, click here : FAQs about the Fee Schedule (PDF).
1. What is the authority under which the schedule of fees is set?
Since 1925, when the Arizona Legislature passed the State's first Workers'
Compensation Act ("Act"), the Industrial Commission of Arizona ("Commission")
has administered the workers' compensation laws of that Act. The Act includes
the authority of the Commission to set a schedule of fees to be charged by physicians,
physical therapists, and occupational therapists attending injured employees. See
A.R.S. § 23-908(B). The Arizona Legislature amended A.R.S. § 23-908 in
2004 to include the setting of fees for prescription medicines required to treat
an injured employee.
2. What is the methodology used by the Commission to establish its schedule of fees?
The Commission surveys the workers’ compensation fee schedules from the states of
Colorado, Nevada, New Mexico, North Carolina, Oregon, Utah, and Washington and uses
the following methodology to calculate the reimbursement values for the codes under
The foregoing methodology does not apply to the following:
- Current Arizona values between the 75th and 100th percentile of the states surveyed
will not be adjusted;
- Current Arizona values over the 100th percentile of the states surveyed will be
reduced to the 100th percentile; and
- Current Arizona values below the 75th percentile will be increased to the 75th percentile
subject to the following: Increases shall be capped at 25%, unless and except as
necessary to bring a current value up to the 50th percentile.
Regarding the formula to calculate the associated percentiles, the Commission uses
the percentile formula in Microsoft® Excel®.
- If the survey sample size is less than four, then the code may be identified as
RNE (Relative Value Not Established) or BR (By Report), except if it involves the
PC (Professional Component) of a value in which case the PC value may be based on
the current ICA PC to Total Value ratio;
- Codes specific to Arizona, the value of which may be determined through the hearing
- Codes otherwise designated as BR.
The following changes have been adopted by the Commission and implemented in the
2015/2016 Fee Schedule:
- Replacing the four-year cycle of review, all codes were reviewed this year. The
form of reporting the codes and values was changed to mirror how this information
is presented commercially, as well as by other states. This included identifying
codes that are "not covered" because they had not previously been adopted the Commission
(e.g., maternity codes, pediatric codes, etc.). This also included identifying,
where applicable, the technical component (TC) of a value. As part of this process,
and to improve the clarity of the information presented, CPT® codes that
contain explanatory language specific to Arizona continued to be preceded by Δ
codes, however, that are unique to Arizona and not otherwise found in CPT-4®
are preceded by an AZ identifier and numbered in the following format: AZ0xx-xxx.
- The Fee Schedule was updated to the 2015 CPT-4® (which became effective
January 1, 2015). The Commission adopted the reference deletions, additions, terminology
changes, general guidelines, identifiers, and modifiers of the 2014 and 2015 CPT®
codes to ensure that the 2015/2016 Fee Schedule is current and reflects the latest
changes to those editions of the CPT-4®. To the extent that a conflict
may exist between the adopted portions of the CPT-4® and a code or guideline
unique to Arizona, the Arizona code or guideline would take precedence.
3. How often is the Arizona Fee Schedule reviewed by the Commission?
The Commission reviews the schedule of fees on an annual basis. The review date
of the Fee Schedule of other jurisdictions for the Arizona 2016 Fee Schedule is
January 31, 2016.
4. When does the annual review of the Fee Schedule take place? Is there an opportunity
to participate in the review process?
Annual updates to the Fee Schedule become effective October 1st of each year. The
public is afforded an opportunity to participate in the process. In early spring
of each year, the Commission provides an analysis of issues along with staff recommendations
for the Fee Schedule (to be effective the following October 1st). This document
is posted on the Commission's website and is intended to serve as a foundational
document for public comment and future discussions that may arise during the public
hearing process. Following the posting of a Notice of Hearing on the Commission's
website, a public hearing is held to receive public comment. Written comments are
welcomed in advance of the public hearing. Thereafter, at a later duly noticed public
meeting, the Commission will take official action on the Fee Schedule. This action
will be incorporated into the Fee Schedule to become effective October 1st of that
5. What fees are covered under the Arizona Fee Schedule?
Under A.R.S. § 23-908(B), the Commission is required to establish a schedule
of fees to be charged by physicians and physical therapists or occupational therapists
attending injured employees. The Commission is also required to establish a schedule
of fees for prescription medicines required to treat an injured employee.
For purposes of the Fee Schedule, the term "physician" includes chiropractors
Fees for certain products, supplies, and services are not included in the Fee Schedule.
This includes fees charged for ambulance services, durable medical equipment, prosthetics,
orthotics, and supplies when used outside a physician's office. If a product,
supply, or services are not included in the Fee Schedule, there will not be a code
for them in the Fee Schedule (e.g., codes from Medicare's Healthcare
Common Procedure Coding System, HCPCS).
6. What is the appropriate fee for products, supplies, or services not covered under
the Fee Schedule? Is it "usual, customary, and reasonable (UCR)"?
If a product, supply, or service is not covered under the Arizona Fee Schedule,
then the Commission has no jurisdiction to set a fee or resolve a fee dispute related
to the service. Additionally, while the obligation of a payer under the Arizona
Workers' Compensation Act is to provide medical benefits that are reasonably
required, neither the Arizona Workers' Compensation Act, A.R.S. § 23-901
et seq., nor the Arizona Physicians' Fee Schedule make reference to the
phrase "usual, customary and reasonable." You may wish to consult an attorney
for further assistance regarding this issue.
7. May a provider bill for services using a code that has not been adopted by the
A provider is not precluded from billing for a service for which there is no corresponding
code in the current Fee Schedule. But, for such a service, since there is no reimbursement
value set forth in the Fee Schedule, reimbursement for the service performed is
subject to negotiation between the parties. See Section (B)(4) of the Fee Schedule
Introduction. As an alternative to billing under a code that has not yet been adopted,
some providers will use an otherwise applicable code or an "unlisted service
or procedure" code in the current Fee Schedule.
8. May a provider covered by the Fee Schedule negotiate a fee that is different from
that in the Fee Schedule?
Yes. Nothing in the Fee Schedule precludes an entity covered under the Fee Schedule
from entering into a separate contract that addresses fees for service.
9. Does the Fee Schedule apply to services provided by out-of-state providers?
The Fee Schedule applies to fees charged by covered entities attending employees
that are entitled to receive workers' compensation benefits under the Arizona
Workers' Compensation Act.
10. Does the Fee Schedule apply to fees charged by chiropractors and naturopaths?
11. Does the Fee Schedule apply to fees charged by nurse practitioners, physician
assistants, or certified nurse anesthetists?
Yes. Certified Registered Nurse Anesthetists are reimbursed at 85% of the Fee Schedule.
Physician Assistants and Nurse Practitioners are reimbursed at 85% of the Fee Schedule
except if services are provided "incident to" a physician's professional
services. In that instance, reimbursement is required to be made at 100% of the
Fee Schedule. See Section C of the Introduction, Reimbursement of Mid-Level Providers,
for additional information.
12. Does the Fee Schedule apply to fees charged by Physical Therapy Assistants?
The Fee Schedule applies to Physical Therapists and not Physical Therapy
Assistants. Please see answers to questions 5 and 6.
13. Does the Fee Schedule apply to fees charged by hospitals or outpatient surgery
No. See also answers to questions 5 and 6.
14. Does the Fee Schedule apply to charges for materials and supplies used in the
A physician is not entitled to be reimbursed for supplies and materials normally
necessary to perform the service. A physician may charge for other supplies and
materials using code 99070. A physician may use an applicable HCPCS code in lieu
of code 99070 if the HCPCS code more accurately describes the materials and supplies
provided by the physician. Examples of those items that are and are not reimbursable
are listed below. Documentation showing actual costs associated with providing supplies
and materials plus fifteen percent (15%) to cover overhead costs will be adequate
justification for payment. This provision does not apply to retail operations involving
drugs or supplies. Administration of drugs to patients in a clinical setting is
covered under code 99070. Prescription drugs provided to patients as a part of the
overall treatment regimen but outside of the clinical setting are not included under
Examples of supplies that are not separately reimbursable:
Applied hot or cold packs
Eye patches, injections, or debridement
Applied eye wash or eye drops
Ultrasound pads and gel
Urine collection kits
Band-Aids® and dressings for simple
Tape for dressing
Examples of material and supplies that are generally reimbursable include:
Cast and strapping materials
Sterile trays for laceration repair and
more complex surgeries
Applied dressings beyond simple wound
Taping supplies for sprains
Reusable patient-specific electrodes
Dispensed items, including canes, braces,
slings, ACE® wraps, TENS electrodes,
crutches, splints, back support, dressings,
hot or cold packs.
15. Does the Fee Schedule apply to charges for ambulance services, durable medical
equipment, prosthetics, orthotic supplies, or surgical implants?
No. See also answers to questions 5 and 6.
16. Does the Fee Schedule apply to fees charged for independent medical examinations?
17. Does the Pharmaceutical Fee Schedule permit a Payer to choose the publication
source for determining Average Wholesale Price?
No. Average wholesale price shall be determined from pricing published in a nationally
recognized pharmaceutical publication designated by the Commission. The Commission
has selected Medi-Span®.
18. What publication is required to be used for purposes of determining Average Wholesale
Average wholesale price shall be determined on the date a drug is dispensed from
pricing published in the most recent issue, as updated in the most recent update,
of a nationally recognized pharmaceutical publication designated by the Commission.
The Commission has selected Medi-Span®.
An entity responsible for payment of prescription drugs may select the following
as an alternative to the foregoing if the selection is made no later than October
1st of each year. This selection shall be communicated in writing to the Commission
and remain in effect until the following October 1st: AWP shall be determined on
the date a drug is dispensed from pricing published in the most recent issue, as
updated quarterly, of the publication designated by the Commission. For purposes
of this paragraph, quarterly means the first day of the month on January, April,
July, and October.
19. Does the Pharmaceutical Fee Schedule apply to repackaged medicines dispensed
by a physician?
The Fee Schedule applies to the dispensing of prescription drugs, regardless of
whether the drug is dispensed by a retail establishment or by a physician. The reimbursement
rate is based on a discount from AWP plus a dispensing fee. The dispensing fee does
not apply to an OTC medication that is not dispensed pursuant to a prescription
20. What is the Average Wholesale Price for repackaged drugs?
For purposes of the Fee Schedule, "average wholesale price" is the average
wholesale price (AWP) established by a wholesaler who sells that brand name or generic
drug to a pharmacy. For a repackaged or compounded drug, this would be the AWP of
the underlying drug product used in the repackaging or compounding. If information
pertaining to the original labeler of the underlying drug product is not provided
or unknown, then discretion is vested in the payer to select the AWP to use (as
published in Medi-Span®) when making payment for the repackaged or compounded
drug. Stated another way, the NDC number upon which reimbursement is based is not
the NDC of the repackager. Instead, reimbursement is based upon the underlying drug
product from the original labeler.
21. I am a physician and I have been subpoenaed to provide telephonic court testimony.
How do I bill for my services?
If the physician wishes to submit an invoice, the invoice must be sent to the Industrial
Commission's Administrative Law Judge Division. The address of this Division is
located on the subpoena that the physician received. The physician is entitled to
bill under code 99099 (expert testimony) at a rate of $110 per hour. The invoice
must include the name of the injured worker and the date that the physician provided