Is there a pamphlet with all this information in it? Yes!
For PDF format, click here : FAQs about the Fee Schedule (PDF).
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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). In 2004, A.R.S. § 23-908 was amended to include the
setting of fees for prescription medicines required to treat an injured employee.
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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. As
a general rule, the Commission selects a value that represents the 75th percentile
of the surveyed values. Exceptions to this general methodology include:
- If the survey sample size is less than four, then the value for the code may be
identified as RNE (Relative Value Not Established) or BR (By
Report), except if it involves the professional component ("PC")
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
process; and
- Codes otherwise designed as BR.
Regarding the formula to calculate the 75th percentile, the Commission uses the
percentile formula in Microsoft Excel.
As a general rule the Commission conforms its Fee Schedule to the changes that have
taken place in the prior year's edition of the CPT. For example, the 2011 Fee
Schedule is updated to reflect the codes from the 2010 edition of the CPT publication.
the follow-up days associated with each procedure are taken from the prior year's
Ingenix publication titled Relative Values for Physicians.
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3. How often is the Arizona Fee Schedule reviewed by the Commission?
The Commission reviews the schedule of fees on an annual basis, subject to the following
schedule:
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2012, 2016
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Surgery Codes 10021 - 24999
Medicine
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2013, 2017
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Surgery Codes 25000 - 39599
Evaluation & Management
Physical Medicine
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2014, 2018
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Surgery Codes 40000 - 59899
Radiology
Special Services
Anesthesia Conversion Factor
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2015, 2019
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Surgery Codes 60000 - 69999
Pathology/Laboratory
Category III Codes
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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. This hearing is typically
held in May of each year, though 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, which will be incorporated in the
Fee Schedule to become effective October 1st of that year.
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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
and naturopaths.
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, then you will not find
a code for them in the Fee Schedule (e.g., codes from Medicare's Healthcare
Common Procedure Coding System, HCPCS).
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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.
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7. May a provider bill for services using a code that has not been adopted by the
Commission?
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 code, 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 alternate 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.
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8. May a provider covered by the Fee Schedule negotiate a fee that is different than
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.
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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.
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10. Does the Fee Schedule apply to fees charged by chiropractors and naturopaths?
Yes.
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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.
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13. Does the Fee Schedule apply to fees charged by Physical Therapy Assistants?
No. See also answers to questions 5 and 6.
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13. Does the Fee Schedule apply to fees charged by hospitals or outpatient surgery
facilities?
No. See also answers to questions 5 and 6.
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14. Does the Fee Schedule apply to charges for materials and supplies used in the
physician's office?
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. 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 clnical setting are not included under
this code.
Examples of supplies that are not separately reimbursable:
Applied hot or cold packs
Eye patches, injections, or debridement
trays
Steristrips
Needles
Syringes
Eye/ear trays
Drapes
Sterile gloves
Applied eye wash or eye drops
Creams (massage)
Fluoroscein
Ultrasound pads and gel
Tissues
Urine collection kits
Gauze
Cotton balls/fluff
Sterile water
Band-Aids® and dressings for simple wound
occlusion
Head sheets
Aspiration trays
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
occlusion
Taping supplies for sprains
Iontophoresis electrodes
Reusable patient-specific electrodes
Dispensed items, including canes, braces,
slings, ACE® wraps, TENS electrodes,
crutches, splints, back support, dressings,
hot or cold packs.
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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.
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16. Does the Fee Schedule apply to fees charged for independent medical examinations?
No.
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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 designed by the Commission. The Commission
has selected Medi-span.
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18. What issue of Medi-span is required to be used for purposes of determining Average
Wholesale Price?
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 designed by the Commission. For purposes of
this paragraph, quarterly means the first day of the month on January, April, July,
and October.
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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.
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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.
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21. I am a physician and I have been subpoenaed to provide telephonic court testimony.
How do I bill for my services?
An invoice should be sent to the Commissions's Administrative Law Judge Division.
The address of this Division is located on the subpoena that you receive. You are
entitled to bill under code 99099 (expert testimony) at a rate of $110 per hour.
Your invoice should include the name of the injured worker and the date that you
provided testimony.
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Last Revised March 5, 2013
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