803 Ky. Admin. Regs. 25:089
Current through Register Vol. 50, No. 11, May 1, 2024
Section 803 KAR 25:089 - Workers' compensation medical fee schedule for physiciansRELATES TO: KRS 342.0011(32), 342.019, 342.020, 342.035
NECESSITY, FUNCTION, AND CONFORMITY: KRS 342.035(1) requires the commissioner of the Department of Workers' Claims to promulgate administrative regulations to ensure that all fees, charges, and reimbursements for medical services under KRS Chapter 342 are limited to charges that are fair, current, and reasonable for similar treatment of injured persons in the same community for like services, where treatment is paid for by general health insurers. KRS 342.035(4) requires the commissioner to promulgate an administrative regulation establishing the workers' compensation medical fee schedule for physicians. KRS 342.035 requires a schedule of fees to be reviewed and updated, if appropriate, every two (2) years on July 1. This administrative regulation establishes the medical fee schedule for physicians.
Section 1. Definitions. (1) "Medical fee schedule" means the 2022 Kentucky Workers' Compensation Schedule of Fees for Physicians.(2) "Physician" is defined by KRS 342.0011(32).Section 2. Services Covered. (1) The medical fee schedule shall govern all medical services provided to injured employees by physicians under KRS Chapter 342.(2) The medical fee schedule shall also apply to other health care or medical services providers to whom a listed CPT code is applicable unless: (a) Another fee schedule of the Department of Workers' Claims applies;(b) A lower fee is required by KRS 342.035 or a managed care plan approved by the commissioner pursuant to 803 KAR 25:110; or(c) An insurance carrier, self-insured group, or self-insured employer has an agreement with a physician, medical bill vendor, or other medical provider to provide reimbursement of a medical bill at an amount lower than the medical fee schedule.Section 3. Fee Computation. (1) The appropriate fee for a procedure or item covered by the medical fee schedule shall be the Maximum Allowable Reimbursement (MAR) listed in the 2022 Kentucky Workers' Compensation Schedule of Fees for Physicians for those procedures or items for which a specific monetary amount is listed.(2) Procedures Listed Without Specified Maximum Allowable Reimbursement Monetary Amount. The appropriate fee for a procedure or item for which a specific monetary amount is not listed shall be determined and calculated in accordance with numerical paragraph six (6) of the General Instructions of the medical fee schedule unless more specific Ground Rules are applicable to that service or item, in which case the fee shall be calculated in accordance with the applicable Ground Rules.(3) The resulting fee shall not be more than the maximum fee allowed for the service provided.Section 4.(1) A physician or healthcare or medical services provider located outside the boundaries of Kentucky shall be deemed to have agreed to comply with this administrative regulation if it treats a patient who is covered under KRS Chapter 342.(2) Pursuant to KRS 342.035, medical fees due to an out-of-state physician or healthcare or medical services provider shall be calculated under the fee schedule in the same manner as for an in-state physician.Section 5. Incorporation by Reference.(1) "2022 Kentucky Workers' Compensation Schedule of Fees for Physicians", July 1, 2022 Edition, is incorporated by reference.(2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Department of Workers' Claims, Mayo-Underwood Building 3rd Floor, 500 Mero Street, Frankfort, Kentucky 40601, Monday through Friday, 8 a.m. to 4:30 p.m.21 Ky.R. 1603; eff. 2-9-1995; 23 Ky.R. 1750; 2485; eff. 12-12-1996; 25 Ky.R. 915; 1362; eff. 11-18-1998; 28 Ky.R. 1226; eff. 1-14-2002; 32 Ky.R. 747; eff. 1-6-2006; 35 Ky.R. 404, eff. 12-5-2008; 37 Ky.R. 1078 1492; eff. 3-4-2011; 40 Ky.R. 1907; 2304; eff. 6-6-2014; 43 Ky.R. 28, 404; eff. 10-7-2016; 45 Ky.R. 158, 1193; eff. 12-7-2018; 47 Ky.R. 382, 1217; eff. 3-2-2021; 49 Ky.R. 440, 1263; eff. 3/7/2023.STATUTORY AUTHORITY: KRS 342.020, 342.035(1), (4)