Section 8 AAC 45.083 - Fees for medical treatment and services(a) A fee or other charge for medical treatment or service may not exceed the maximums in AS 23.30.097. The fee or other charge for medical treatment or service (1) provided on or after December 1, 2015, but before April, 2017, may not exceed the fee schedules set out in (b) - (l) of this section;(3) provided on or after January 1, 2018, but before January 1, 2019, may not exceed the maximum allowable reimbursement established in the Official Alaska Workers' Compensation Medical Fee Schedule, effective January 1, 2018, and adopted by reference.(4) provided on or after January 1, 2019, but before January 1, 2020, may not exceed the maximum allowable reimbursement established in the Official Alaska Workers' Compensation Medical Fee Schedule, effective January 1, 2019, and adopted by reference.(5) provided on or after January 1, 2020, but before January 1, 2021, may not exceed the maximum allowable reimbursement established in the Official Alaska Workers' Compensation Medical Fee Schedule, effective January 1, 2020, and adopted by reference;(6) provided on or after January 1, 2021, but before February 24, 2022, may not exceed the maximum allowable reimbursement established in theOfficial Alaska Workers' Compensation Medical Fee Schedule, effective January 1, 2021, and adopted by reference;(7) provided on or after February 24, 2022, but before January 1, 2022, may not exceed the maximum allowable reimbursement established in the Official Alaska Workers' Compensation Medical Fee Schedule, January 1, 2022 edition, adopted by reference.(8) provided on or after January 1, 2023, may not exceed the maximum allowable reimbursement established in the Official Alaska Workers' Compensation Medical Fee Schedule, January 1, 2023 edition, and adopted by reference.(b) For medical services provided by physicians under AS 23.30 (Alaska Workers' Compensation Act) the following conversion factors shall be applied to the total facility or non-facility relative value unit in the Resource-Based Relative Value Scale, adopted by reference in (m) of this section. Medical service or treatment shall be identified by a code assigned to that treatment or service in the Current Procedural Terminology, adopted by reference in (m) of this section: (1) the conversion factor for evaluation and management is $80;(2) the conversion factor for medicine, excluding anesthesiology, is $80;(3) the conversion factor for surgery is $205;(4) the conversion factor for radiology is $257;(5) the conversion factor for pathology and laboratory is $142;(6) the relative value for Current Procedural Terminology code 97545 is 3.41, and the relative value for Current Procedural Terminology code 97546 is 1.36.(c) The conversion factor for anesthesiology is $121.82, which is to be multiplied by the base and time units for each Current Procedural Terminology code established in the Relative Value Guide, adopted by reference in (m) of this section.(d) For supplies, materials, injections, and other services and procedures coded under the Healthcare Common Procedure Coding System, adopted by reference in (m) of this section, the following multipliers shall be applied to the following fee schedules established by the Centers for Medicare and Medicaid Service and in effect at the time of treatment or service; (1) Cinical Diagnostic Laboratory services, multiplied by 6.33;(2) Durable Medical Equipment, Prosthetics, Orthetics, and supplies (DMEPOS), multiplied by 1.84;(3) Average Sale Price, Payment Allowance Limits for Medicare Part B Drugs, multiplied by 3.375;(e) For medical services provided by inpatient hospitals under AS 23.30 (Alaska Workers' Compensation Act) the conversion factor of 328.2 percent of the hospital specific total base rate shall be applied to the Medicare Severity Diagnosis Related Groups weight adopted by reference in (m) of this section, except that (1) the maximum allowable reimbursement for medical services provided by a critical access hospital, rehabilitation hospital, or long term acute care hospital is the lowest of 100 percent of billed charges, the charge for the treatment or service when provided to the general public, or the charge for the treatment or service negotiated by the provider and the employer;(2) the base rate for Providence Alaska Medical Center is $23,383.10;(3) the base rate for Mat-Su Regional Medical Center is $20,976.66;(4) the base rate for Bartlett Regional Hospital is $20,002.93;(5) the base rate for Fairbanks Memorial Hospital is $21,860.73;(6) the base rate for Alaska Regional Hospital is $21,095.72;(7) the base rate for Yukon Kuskokwim Delta Regional Hospital is $38,753.21;(8) the base rate for Central Peninsula General Hospital is $19,688.56;(9) the base rate for Alaska Native MedicaI Center is $31,042.20;(10) the base rate for Mt. Edgecumbe Hospital is $26,854.53;(11) on outlier cases, implants shall be paid at invoice plus 10 percent.(f) For medical services provided by hospital outpatient clinics or ambulatory surgical centers under AS 23.30 (Alaska Workers' Compensation Act), an outpatient conversion factor of $221.79 shall be applied to the relative weights established for each Current Procedural Terminology or Ambulatory Payment Classification code adopted by reference in (m) of this section. For procedures performed in an outpatient setting, implants shall be paid at invoice plus 10 percent.(g) The maximum allowable reimbursement for medical services that do not have current Centers for Medicare and Medicaid Services, Current Procedural Terminology, or Healthcare Common Procedure Coding System codes, a currently assigned Centers for Medicare and Medicaid Services relative value, or an established conversion factor is the lowest of 85 percent of billed charges, the charge for the treatment or service when provided to the general public, or the charge for the treatment or service negotiated by the provider and the employer.(h) The maximum allowable reimbursement for prescription drugs is as follows: (1) brand name drugs shall be reimbursed at the manufacturer's average wholesale price plus a $5 dispensing fee;(2) generic drugs shall be reimbursed at manufacturer's average wholesale price plus a $10 dispensing fee;(3) reimbursement for compounded drugs shall be limited to medical necessity and reimbursed at the manufacturer's average wholesale price for each drug included in the compound, listed separately by National Drug Code, plus a $10 compounding fee.(i) The maximum allowable reimbursement for lift off fees and air mile rates for air ambulance services rendered under AS 23.30 (Alaska Workers' Compensation Act) is as follows: (1) for air ambulance services provided entirely in this state that are not provided under a certificate issued under 49 U.S.C. 41102 or that are provided under a certificate issued under 49 U.S.C. 41102 for charter air transportation by a charter air carrier, the maximum allowable reimbursements are as follows: (A) a fixed wing lift off fee may not exceed $11,500;(B) a fixed wing air mile rate may not exceed 400 percent of the Centers for Medicare and Medicaid Services ambulance fee schedule rate in effect at the time of service;(C) a rotary wing lift off fee may not exceed $13,500;(D) a rotary wing air mile rate may not exceed 400 percent of the Centers for Medicare and Medicaid Services ambulance fee schedule rate in effect at the time of service;(2) for air ambulance services in circumstances not covered under (1) of this subsection, the maximum allowable reimbursement is 100 percent of the billed charges.(j) The following billing and payment rule apply for medical treatment or services provided by Physicians. Providers and payers shall follow the billing and coding rules adopted by reference in (m) of this section as established by the Centers for Medicare and Medicaid Services and the American Medical Association, including the use of modifiers. The procedure with the largest relative value unit is the primary procedure and shall be listed first on the claim form. Specific modifiers shall be reimbursed as follows: (1) Modifier 50: reimbursement is the lowest of 100 percent of the fee schedule amount or the billed charge for the procedure with the highest relative value unit; reimbursement is the lowest of 50 percent of the fee schedule amount or the billed charge for the procedure for the second and all subsequent procedure;(2) Modifier 51: reimbursement is the lowest of 100 percent of the fee schedule amount or the billed charge for the procedure with the highest relative value unit rendered during the same session as the primary procedures; reimbursement is the lowest of 50 percent of the fee schedule amount or the billed charge for the procedure for the second highest relative value unit and all subsequent procedures during the same session as the primary procedure;(3) Modifier 80, 81 and 82: reimbursement is 20 percent of the surgical procedure;(4) Modifier PE: reimbursement is 85 percent of the value of the procedure; state specific modifier PE shall be used when services and procedures are provided by a physician assistant or an advanced practice registered nurse;(5) Modifier AS: reimbursement is 15 percent of the value of the procedure; state specific modifier AS shall be used when a physician assistant or nurse practitioner acts as an assistant surgeon and bills as an assistant surgeon;(6) Modifier QZ: reimbursement is 85 percent of the value of the anesthesia procedure; state specific modifier QZ shall be used when unsupervised anesthesia services are provided by a certified registered nurse anesthelist;(7) providers and payers shall follow National Correct Coding Initiative edits established by the Centers for Medicare and Medicaid Services and the American Medical Association in effect at the time of treatment; if there is a billing rule discrepancy between National Correct Coding Initiative edits and the American Medical Association Current Procedural Terminology Assistant, American Medical Association Current Procedural Terminology Assistant guidance governs.(k) The following billing and payment rules apply for medical treatment or services provided by inpatient hospitals, hospital outpatient clinics, and ambulatory surgical centers: (1) medical service for which there is no Ambulatory Payment Classifications weight listed are the lowest of 85 percent of billed charges, the fee or charge for the treatment or service when provided to the general public, or the fee or charge for the treatment or service negotiated by the provider and the employer;(2) status codes C, E, and P are the lowest of 85 percent of billed charges, the fee or charge for the treatment or service when provided to the general public, or the fee or charge for the treatment or service negotiated by the provider and the employer;(3) two or more medical procedures with a status code T on the same claim shall be reimbursed with the highest weighted code paid at 100 percent of the Ambulatory Payment Classifications calculated amount and all other status code T items paid at 50 percent;(4) a payer shall subtract implantable hardware from a hospital outpatient clinic's or ambulatory surgical center's billed charges and pay separately at manufacturer or supplier invoice cost plus 10 percent;(5) if total costs for a hospital inpatient Medicare Severity Diagnosis Related Groups coded service exceeds the Centers for Medicare and Medicaid Services outlier threshold established at the time of service plus the Medicare Severity Diagnosis Related Groups payment, then the total payment for that service shall be calculated using the Centers for Medicare and Medicaid Services Inpatient PC Pricer tool as follows: (A) implantable charges, if applicable, are subtracted from the total amount charged;(B) the charged amount from (A) of this paragraph is entered into the most recent version of the Centers for Medicare and Medicaid Services PC Pricer tool at the time of treatment;(C) the Medicare price returned by the Centers for Medicare and Medicaid Services PC Pricer tool is multiplied by 2.5, or 250 percent of the Medicare price;(D) the allowable implant reimbursement, if appliable, is the invoice cost of the implant plus 10 percent, or 110 percent of invoice cost;(E) the amounts calculated in (C) and (D) of this paragraph are added together to determine the final reimbursement.(l) For medical treatment or services provided by other providers, the maximum allowable reimbursement for medical services provided b providers other than physicians, hospitals, outpatient clinics, or ambulatory surgical centers is the lowest of 85 percent of billed charges, the fee or charge for the treatment or service when provided to the general public, or the fee or charge for the treatment or service negotiated by the provider and the employer.(m) The following material is adopted by reference: (1)Current Procedural Terminology Codes, 2015 edition, produced by the American Medical Association, as may be amended;(2)Healthcare Common Procedure Coding System, 2015 edition, produced by the American Medical Association, as may be amended;(3)International Classification of Diseases, 10th Revision, Clinical Modification, developed by the National Center for Health Statistics, as may be amended;(4)Relative Value Guide, 2015 edition, produced by the American Society of Anesthesiologists, as may be amended;(5)Diagnostic and Statistical Manual of Mental Disorders, 5th edition, produced by the American Psychiatric Association, as may be amended;(6)Current Dental Terminology, 2015 edition, published by the American Dental Association, as may be amended;(7)Resource-Based Relative Value Scale, effective January 1, 2015 produced by the federal Centers for Medicare and Medicaid Services, as may be amended;(8)Ambulatory Payment Classifications, effective January 1, 2015 produced by the federal Centers for Medicare and Medicaid Services, as may be amended;(9)Medicare Severity Diagnosis Related Groups, effective January 1, 2015 produced by the federal Centers for Medicare and Medicaid Services, as may be amended;(10)Hospital Outpanent Prospective Payment System, dated effective January 1, 2023, produced by the federal Centers for Medicare and Medicaid Services;(11)Clinical Diagnostic Laboratory Services, produced by the federal Centers for Medicare and Medicaid Services, as may be amended;(12)Durable Medical Equipment, Prosthetics, Orthotics, and Supplies, produced by the federal Centers for Medicare and Medicaid Services, as may be amended; (13)Payment Allowance Limits for Medicare Part B Drugs, Average Sale Price, produced by the federal Centersf of Medicare and Medicaid Services, as may be amended; (14)Ambulance Fee Schedule, produced by the federal Centers for Medicare and Medicaid Services, as may be ameitded.Eff. 12/1/2015, Register 216, January 2016; am 3/11/2016, Register 217, April 2016; am 4/1/2017, Register 221, April 2017; am 1/1/2018, Register 224, January 2018; am 1/1/2019, Register 228, January 2019; am 5/12/2019, Register 230, April 2019; am 12/21/2019, Register 232, January 2020; am 1/1/2021, Register 236, January 2021; am 2/24/2022, Register 241, April 2022; am 1/29/2023, Register 245, April 2023Authority:AS 23.30.005
AS 23.30.097
AS 23.30.098