Professional Services Fee Schedule - lni.wa.gov

1 Professional Services Fee ScheduleLocal CodesEffective July 1, 2017To Skip the Keys&Go To The FeesClick HereProfessional Services Fee ScheduleLocal Code FeesEffective for Dates of Service on or AfterJuly 1, 2017 Refer to Field Key for definitions Local Codes Page 1 Professional Services Fee ScheduleLocal CodesEffective July 1, 2017 This document is also on the department s Internet web site at Updates to this manual can be found under Updates and Corrections tab on the department s Internet web site at to this manual are also announced on the Medical Provider e-News listserv. Individuals may join the listserv at to Field Key for definitions Local Codes Page 2 Professional Services Fee ScheduleLocal CodesEffective July 1, 2017 LOCAL CODES FEE SCHEDULEC olumn TitleValue DefinitionsDescriptionDescription of the unique dollar amount payable for covered fee or RVUs available, code paid By ReportReserved for a special programService paid at state rate for travel or dollar amount payable for covered fee or RVUs available.

2 Code paid By ReportReserved for a special programService paid at state rate for travel or Value Nonfacility SettingLocal Code DescriptionState RateDollar ValueBy ReportDollar Value Facility SettingProgram OnlyLOCALCODEC ontractedContracted service. Payable only to department s contracted vendor for State Fund claims. Payable to providers treating Self-Insured injured service. Payable only to department s contracted vendor for State Fund claims. Payable to providers treating Self-Insured injured ValueBy ReportContractedThis column indicates the:Maximum dollar amount for covered Services provided in a non-facility setting, orPricing method for the procedure codeFIELD KEY: A code assigned by the department to represent a specific service that is unique to injured Local DescriptionColumn ValuesState RateProgram OnlyThis column indicates the.

3 Maximum dollar amount for covered Services provided in a facility setting, orPricing method for the procedure codeRefer to Field Key for definitions Local Codes Page 3 Professional Services Fee ScheduleLocal CodesEffective July 1, 2017 Column TitleValue DefinitionsField Key: Local Codes (continued)Column DescriptionColumn ValuesSpecial PilotThe code is reserved for a special pilot onlyThe reason for the code or a reference to a page in another document where the reason for the code can be foundPayment Policy ReferenceFacility ServicesThere is a reference to the code within the Facility Services reimburse claimant s costsReference to payment policies related to the local ServicesThere is a reference to the code within the Professional Services to Field Key for definitions Local Codes Page 4 Professional Services Fee ScheduleLocal CodesEffective July 1.

4 2017 Local CodeDescriptionNON-FACILITY FEEFACILITY FEEP ayment Policy Reference0010 EAnkle weight purchaseBy ReportBy ReportTo reimburse claimant costs0012 EWrist weight purchaseBy ReportBy ReportTo reimburse claimant costs0301 RRetraining, plan travel, mileageState RateState RateTo reimburse claimant costs0302 RRetraining, plan travel, parkingBy ReportBy ReportTo reimburse claimant costs0303 RRetraining, plan travel, bridge/ferry tollBy ReportBy ReportTo reimburse claimant costs0304 RRetraining, plan travel, commercial transportationBy ReportBy ReportTo reimburse claimant costs0375 RRetraining, relocation costsBy ReportBy ReportTo reimburse claimant costs0378 RStand alone job analysis, non-voc$ $ Services0380 RJob modificationBy ReportBy ReportProfessional Services0385 RPre-job accommodationBy ReportBy ReportProfessional Services0388 RPlan development Services , non-vocBy ReportBy ReportProfessional Services0389 RJob mod/pre-job mod - non voc, job mod/pre-job mod$ $ Services0390 RVocational evaluation - non voc, ea 6 minutes, work eval$ $ Services0391 RTravel / wait (non-voc), travel / wait 9non-voc)

5 $ $ Services0392 RMileage, non-vrc, per mileState RateState RateProfessional Services0393 RFerry and bridge charges, non-vocationalState RateState RateProfessional Services0395 RDept of personnel rtrn to wrk srvcsBy ReportBy Report0401 AClaimant - private transportation, per mileState RateState RateTo reimburse claimant costs0402 AClaimant - parkingBy ReportBy ReportTo reimburse claimant costs0403 AClaimant - bridge ferry tollsBy ReportBy ReportTo reimburse claimant costs0405 AClaimant - commercial fare (airlines, railroad)By ReportBy ReportTo reimburse claimant costs0406 AClaimant - lodging (hotel/motel)State RateState RateTo reimburse claimant costs0407 AClaimant - breakfastState RateState RateTo reimburse claimant costs0408 AClaimant - lunchState RateState RateTo reimburse claimant costs0409 AClaimant - dinnerState RateState RateTo reimburse claimant costs0411 AClaimant - time lost from work to attend department or self-insurer requested imeBy ReportBy ReportTo reimburse claimant costs0412 AClaimant - travel related to a department or self-insurer requested examState RateState RateTo reimburse claimant costs0413 AClaimant - miscellaneous travel (must specify)

6 State RateState RateTo reimburse claimant costs0414 AClaimant - taxi one way, or mileageBy ReportBy ReportTo reimburse claimant costs0415 AClaimant - replacement of clothingBy ReportBy ReportTo reimburse claimant costs0420 ALumbar seat supportBy ReportBy ReportTo reimburse claimant costs0426 ASilicone elastomer/scar conformerBy ReportBy ReportTo reimburse claimant costs0440 AWt loss prog,joining fee,worker reimburs$ $ reimburse claimant costsLocal Code FeesRefer to Field Key for definitions Local Codes Page 5 Professional Services Fee ScheduleLocal CodesEffective July 1, 2017 Local CodeDescriptionNON-FACILITY FEEFACILITY FEEP ayment Policy ReferenceLocal Code Fees0441 AWt loss prog,weekly fee,worker reimburse$ $ reimburse claimant costs0800 VEarly intervention Services $ $ Services0801 VEarly intervention Services - intern$ $ Services0802 VEarly interv, graduated rtw - vrc$ $ Services0803 VEarly interv.

7 Graduated rtw - intern$ $ Services0808 VStand alone job analysis ref voc$ $ Services0809 VStand alone job analysis ref intern$ $ Services0810 VAssessment Services $ $ Services0811 VAssessment Services - intern$ $ Services0812 VAssessment Services exception- vrc$ $ Services0813 VAssessment Services exception- intern$ $ Services0821 VVocational evaluation$ $ Services0823 VPre-job or job modification consult$ $ Services0824 VPre-job or job mod consult-intern$ $ Services0830 VPlan development Services $ $ Services0831 VPlan development Services -intern$ $ Services0840 VPlan implementation Services $ $ Services0841 VPlan implementation Services -intern$ $ Services0842 VPlan implementation Services exception - vrc$ $ Services0843 VPlan implementation Services exception - intern$ $ Services0844 VResume Services - vrc$ $ Services0845 VResume Services - intern$ $ Services0881 VForensic Services $ $ Services0891 VTravel/wait time$ $ Services0892 VTravel/wait time - intern$ $ Services0893 VProfessional mileage, vrc, per mileState RateState RateProfessional Services0894 VProfessional mileage, intern, per mileState RateState RateProfessional Services0895 VAir travel, vrc, intern.

8 Or forensic vrcBy ReportBy ReportProfessional Services0896 VFerry and bridge charges (voc)By ReportBy ReportProfessional Services0897 VHotel charges (voc) [out-of-state only]By ReportBy ReportProfessional Services1001 MWork hardening eval, per hour$ $ Services1026 MAP final report at request of insurer$ $ Services1027 MLep form by a/p at insurer's request$ $ Services1028 MReview of job offer/analysis by a/p$ $ Services1038 MRevw job offer/analysis for empl,per job$ $ ServicesRefer to Field Key for definitions Local Codes Page 6 Professional Services Fee ScheduleLocal CodesEffective July 1, 2017 Local CodeDescriptionNON-FACILITY FEEFACILITY FEEP ayment Policy ReferenceLocal Code Fees1040 MAccident report.

9 Completion$ $ Services1041 MReopening application$ $ Services1044 MPt in remote areas$ $ Services1045 MPhysical capacities exam (pce)$ $ Services1046 MProvider travel per mile, round trip exc$ $ Services1055 MOccupational disease hx, detailed, non-i, occupati$ $ Services1061 MClaimant - per diem lodging/mealsBy ReportBy ReportTo reimburse claimant costs1063 MIme-ap review requested by dept.$ $ Services1065 MAttending doctor ime review written repo$ $ Services1066 MProvider review of video materials with reportBy ReportBy ReportProfessional Services1067 MAssess impeds to rtrn to work, mentorNot CoveredNot CoveredSpecial Pilot1068 MAssess impediments to rtrn to wrk, appNot CoveredNot CoveredSpecial Pilot1070 MRefer for assessment of impediments$ $ Pilot1071 MQuality indicator incentive payment$ $ Pilot1073 MActivity prescription form, insurer requested$ $ Services1074 MAP response to vrc/employer request re.

10 RTW$ $ Services1076 MOpioid req for subacute pain w/o doc$ $ Services1077 MOpioid req for subacute pain w/doc$ $ Services1078 MOpioid request for chronic pain$ $ Services1104 MIme-addendum report$ $ Services1105 MIme-physical capacities estimate$ $ Services1108 MIme-standard, single$ $ Services1109 MIme-complex, single$ $ Services1111 MIme-no show fee, single,standard/complex$ $ Services1112 MIme-additional examiner$ $ Services1118 MIme-by psychiatrist$1, $1, Services1120 MIme-no show fee, psych$ $ Services1122 MIme pain management impairment rating$ $ Services1123 MIme - communication issues$ $ Services1124 MIme, other, by reportBy ReportBy ReportProfessional Services1125 MIme-phys travel per mile, round trip exc$ $ Services1128 MIme - occupational disease hx$ $ Services1129 MIme - extensive file review by examiner$ $ Services1130 MIme - terminated examination$ $ Services1132 MIme document handling fee, per page$ $ ServicesRefer to Field