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Medical fee guideline FAQ

Fee guidelines home 

As part of 28 TAC §§134.203(c)(2), DWC adopted a provision that will automatically update the conversion factors each year based on the MEI. The MEI annual percentage adjustment is published each November in the Federal Register as a part of the Medicare Physician Fee Schedule update. DWC monitors the annual percentage adjustment change to the MEI and posts the conversion factors for the subsequent year on its website in December.

Conversion factors for workers' compensation medical fee guidelines

The Centers for Medicare and Medicaid Services (CMS) provides free Medicare reimbursement information. These basic steps are used to calculate the MAR amount. Much of the information in these steps is available on the CMS website. DWC also uses this method to resolve medical fee disputes.

Step 1. (A) – Multiply the work value by the geographic practice cost index (GPCI) work value = geographically adjusted work value.

(Work x GPCI)

Step 2. (B) – Multiply the appropriate practice expense* (PE) by the GPCI PE = geographically adjusted PE value.

(PE x GPCI PE)

Step 3. (C) – Multiply the malpractice expense (MP) by the GPCI MP = geographically adjusted MP value.

(MP x GPCI MP)

Step 4. (D) – Add the three geographically adjusted values (A) + (B) + (C) = total relative value units (RVUs).

(Work x GPCI) + (PE x GPCI PE) + (MP x GPCI MP) = RVUs

Step 5. MAR – Multiply the total RVUs (D) by the DWC Conversion Factor.

RVUs x DWC conversion factor = MAR

Note: *In calendar years where CMS uses transitional RVUs, use the transitional rates to calculate MAR. You may estimate reimbursement by dividing the DWC conversion factor by the Medicare conversion factor, then multiply that amount by the Medicare participating reimbursement amount for the service.

28 TAC §134.1 specifies that medical reimbursements for health care services provided to injured employees subject to a workers’ compensation health care network established under Texas Insurance Code Chapter 1305 be made in accordance with the provisions of that chapter. There are two exceptions:

(A) Required medical examinations under Texas Labor Code §408.004, and designated doctor examinations under Texas Labor Code §§408.0041 and 408.151 shall be reimbursed in accordance with 28 TAC §§134.235, 134.240, and 134.250; and

(B) treating doctor examinations to define compensable injury under Texas Labor Code §408.0042 shall be reimbursed in accordance with 28 TAC §126.14.

Texas Insurance Code §§1305.006 and 1305.153 provide that the following types of out-of-network health care are reimbursed under DWC Medical Fee Guidelines:

  • emergency care,
  • health care provided to an injured employee who does not live within the service area of any network established by the insurance carrier or with which the insurance carrier has a contract; and 
  • health care provided by an out-of-network provider pursuant to a referral from the injured employee’s treating doctor that has been approved by the network pursuant to Texas Insurance Code §1305.103.

No. One of the criteria for designation as a workers’ compensation underserved area is that the ZIP code can’t be in a HPSA. Workers’ compensation underserved areas and HPSAs are designed to be mutually exclusive; however, if CMS adds new HPSAs that duplicate a workers’ compensation underserved area ZIP code, the health care provider may only be paid according to the HPSA allowance, not the allowance for workers’ compensation underserved areas.

No. Worker’s compensation incentive payments are paid based on the ZIP code where the medical service is provided (Block 32 on the CMS-1500 form).

Yes, workers’ compensation underserved area incentive payments are paid to all health care providers when billing for medical services. Note: These rules indicate that the workers’ compensation underserved area incentive payment is not applicable:

  • when there is a negotiated or contracted amount;
  • home health services;
  • return to work rehabilitation programs;
  • work status reports; and
  • treating doctor examinations to define the compensable injury.

In 28 TAC §134.220, DWC set the case management fees for treating doctors using 2007 AMA CPT Codes and descriptors to ensure uniform reimbursement.

CPT Code Description Treating doctor modifier Treating doctor Contributing HCP (no modifier)
99361 Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care (patient not present); approximately 30 minutes W1 $113 $28
99362 Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care (patient not present); approximately 60 minutes W1 $198 $50
99371 Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care professionals (e.g., nurses, therapists, social workers, nutritionists, physicians, pharmacists); simple or brief (e.g., to report on tests and/or laboratory results, to clarify or alter previous instructions, to integrate new information from other health professionals into the medical treatment plan, or to adjust therapy) W1 $18 $5
99372 Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care professionals (e.g., nurses, therapists, social workers, nutritionists, physicians, pharmacists); intermediate (e.g., to provide advice to an established patient on a new problem, to initiate therapy that can be handled by telephone, to discuss test results in detail, to coordinate medical management of a new problem in an established patient, to discuss and evaluate new information and details, or to initiate new plan of care) W1 $46 $12
99373 Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care professionals (e.g., nurses, therapists, social workers, nutritionists, physicians, pharmacists); complex or lengthy (e.g., lengthy counseling session with anxious or distraught patient, detailed or prolonged discussion with family members regarding seriously ill patient, lengthy communication necessary to coordinate complex services of several different health professionals working on different aspects of the total patient care plan) W1 $90 $23

 

The treating doctor is responsible for coordinating the health care provided to the injured employee and for initiating case management services. Health care providers should coordinate with the treating doctor to create a treatment plan in order to receive the reimbursement allowed by 28 TAC §134.220.

No. The maximum allowable reimbursement amounts for DME are specified in 28 TAC §134.203(d). DWC adopts updates to the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule as they occur.

Home health services must be provided through a licensed home health agency as noted in 28 TAC §134.215. Home health agencies in Texas are licensed by the Texas Health and Human Services Commission. See licensing requirements.

Home health services provided through a licensed home health agency are reimbursed at 125% of the published Texas Medicaid Fee Schedule for Home Health Agencies. The Texas Medicaid Fee Schedule is available through the Texas Medicaid and Healthcare Partnership (TMHP) website.

Home health services should be billed following the instructions contained in 28 TAC §133.10 (Billing Forms/Formats) and 28 TAC §133.500 (Electronic Formats for Electronic Medical Bill Processing).

Instructions for completing paper and electronic medical bills.

Some pathology service codes are found in the Medicare Physician Fee Schedule (MPFS). In such instances, calculate reimbursement in the same way as described in “Calculating MAR for Evaluation and Management, Medicine, Surgery, Radiology, Pathology, and Physical Medicine.”

If a pathology service code is not found in the MPFS, look it up in the Medicare Clinical Laboratory Fee Schedule.

Pathology/laboratory codes have technical and professional components. When using the Medicare Clinical Laboratory Fee Schedule, reimbursement amounts are as follows:

Technical component = 125% of Medicare Clinical Laboratory Fee Schedule amount

  • Medicare x 1.25 = technical component MAR

Professional component = 45% of MAR for the technical component

  • Technical component MAR x .45 = professional component MAR

Whole procedure = sum of technical and professional components

  • Technical component MAR + professional component MAR = whole procedure MAR

The Texas workers’ compensation system does not use the Medicare anesthesia conversion factors. DWC uses the same conversion factor for anesthesiology as for other professional CPT service groupings.

To calculate the MAR for anesthesiology services in which there are four-time units and three base units, use this formula:

MAR = (time + base) x DWC conversion factor

Example:

MAR = (4 + 3) x DWC conversion factor

MAR = 7 x DWC conversion factor

CMS Anesthesiologists Center

For more information, contact: CompConnection@tdi.texas.gov

Last updated: 4/14/2022