Schedule of Medical and Hospital Fees

1 Schedule of Medical and Hospital fees Effective January 1, 2012 Updated January 19, 2012 Michael Clingman Administrator Adopted December 22, 2011 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital fees Effective 01/01/12 NOTICE The five character codes included in the Schedule of Medical fees are obtained from Current Procedural Terminology, (CPT7), copyright 2010 by the American Medical Association (AMA). CPT7 is developed by the AMA as a listing of descriptive terms and five-character identifying codes and modifiers for reporting Medical services and procedures. The responsibility for the content of the Schedule of Medical and Hospital fees is with the State of Oklahoma Workers Compensation Court and no endorsement by the AMA is intended or should be implied.

2 The AMA disclaims any responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in the Schedule of Medical and Hospital fees . Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT7, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense Medical services. The AMA assumes no liability for data contained or not contained herein. Any use of CPT7 outside the Schedule of Medical and Hospital fees should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT7 codes and descriptive terms.

3 Applicable FARS/DFARS apply. CPT7 is a registered trademark of the American Medical Association. Oklahoma Workers= Compensation Court Schedule of Medical and Hospital fees Effective 01/01/12 Table of Contents Foreword .. 1 Introduction .. 1 general Ground Rules .. 5 Evaluation and Management .. 15 Anesthesia .. 19 Surgery .. 27 Radiology .. 95 Pathology .. 107 Medicine .. 125 Physical Medicine .. 139 Dental Services .. 145 Durable Medical Equipment, Supplies, Orthotics and Prostheses .. 147 Ambulance Services .. 149 Pharmaceutical Services .. 151 Ambulatory Surgical Center Services .. 155 Inpatient Hospital Services .. 157 Inpatient Rehabilitation Facility Services .. 181 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital fees Effective 01/01/12 This page intentionally left blank.

4 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital fees Effective 01/01/12 FOREWORD The Schedule of Medical and Hospital fees outlines maximum reimbursement levels for health care providers, including hospitals and ambulatory surgical centers, rendering health care services to injured employees as provided in the Workers' Compensation Code, 85 , Section 301 et seq. It applies to all health care services rendered after December 31, 2011 to employees with compensable injuries, regardless of the employee's date of injury. The Schedule of Medical and Hospital fees does not apply to: (1) health care services performed under a certified workplace Medical plan provided for in 85 , Section 328; (2) health care services performed under a written contract between a health care provider and an employer or insurance carrier entered into pursuant to 85 , Section 327(E); (3) health care services for which voluntary payments in excess of the reimbursement levels of the Schedule are made by a self-insured employer or an insurance carrier.

5 Or (4) disability evaluations provided as Medical -legal evidence and performed by independent Medical examiners appointed by the Workers= Compensation Court as provided in the Workers Compensation Code. Reimbursement of Court-appointed independent Medical examiners is governed by Workers= Compensation Court Rule 44. This Schedule was adopted on December 22, 2011 as provided in 85 , Section 327. The Schedule of Medical fees is based on the most current Relative Value Units (RVU) produced by the Centers for Medicare and Medicaid Services (CMS) for the Medicare Physician Fee Schedule . The inpatient Hospital services portion of the Schedule utilizes the Medical Severity Diagnosis Related Groups (MS-DRG) system as the primary coding system for health care services rendered.

6 The inpatient rehabilitation facility services portion of the Schedule utilizes the Case-Mix Groups (CMG) system as a coding system for health care services rendered. The Schedule also adopts by reference the Centers for Medicare and Medicaid Services, CMS Healthcare Common Procedures Coding System (HCPCS) for the coding of certain supplies and materials, and for ambulance services. INTRODUCTION 1. PROCEDURE CODES: For purposes of the Schedule of Medical fees , health care services and procedures shall be described in accordance with current procedural terminology codes and descriptions listed in the Physicians' Current Procedural Terminology, (CPT7), copyright 2010 by the American Medical Association.

7 The accompanying instructions and ground rules of the Schedule of Medical fees explain the application of these procedure descriptors and values in Medical practice. All matters not specifically governed by the provisions of the Schedule of Medical fees shall be subject to the provisions of CPT7 2011. If the provisions of the Schedule of Page 1 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital fees Effective 01/01/12 Medical fees conflict with the provisions of CPT7 2011, the provisions of the Schedule of Medical fees shall govern. The five character codes included in the Schedule of Medical fees are obtained from Current Procedural Terminology, (CPT7), copyright 2010 by the American Medical Association (AMA).

8 CPT7 is developed by the AMA as a listing of descriptive terms and five-character identifying codes and modifiers for reporting Medical services and procedures. The responsibility for the content of the Schedule of Medical and Hospital fees is with the State of Oklahoma Workers= Compensation Court and no endorsement by the AMA is intended or should be implied. The AMA disclaims any responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in the Schedule of Medical and Hospital fees . Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT7, and the AMA is not recommending their use.

9 The AMA does not directly or indirectly practice medicine or dispense Medical services. The AMA assumes no liability for data contained or not contained herein. Any use of CPT7 outside the Schedule of Medical and Hospital fees should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT7 codes and descriptive terms. Applicable FARS/DFARS apply. CPT7 is a registered trademark of the American Medical Association. Allowables found in the right hand column of the Schedule of Medical and Hospital fees were developed by the Administrator of the Oklahoma Workers' Compensation Court pursuant to 85 , Section 327. 2.

10 FORMAT: The Oklahoma Schedule of Medical and Hospital fees consists of fourteen sections: Evaluation and Management; Anesthesia; Surgery; Radiology; Pathology; Medicine; Physical Medicine; Dental Services; Durable Medical Equipment, Supplies, Orthotics and Prostheses; Ambulance Services; Pharmaceutical Services; Ambulatory Surgical Center Services; Inpatient Hospital Services; and Inpatient Rehabilitation Facility Services. The Schedule is divided into these sections for structural purposes only. Providers of Medical services and/or suppliers are to use the section(s) which contain the procedures they perform, or the services they render.