Effective for all dates of service on or after April 1, 2016, the DWC adopted changes to the Physician Services and Non-Physician Practitioner Services fee schedule. Reimbursement amounts decreased by approximately 0.06%, with the exception of anesthesia services, for which reimbursements decreased by approximately 1.99%.
These changes affect all 17,500+ Physician Fee Schedule reimbursements. For more detail about the DWC changes, read the DIR Newsline 2016-35.
The changes to the Physician Fee Schedule include adoption of new:
- Conversion Factors
- Medically Unlikely Edits (MUEs)
- Practitioner PTP Edits
- Relative Value File (RVU file)
If you use either DaisyBill’s billing software or calculator software, DaisyBill’s software is already up-to-date with these reimbursement changes. See the example below for the new reimbursement for CPT 99214.
Stop scrambling when the OMFS changes, subscribe to DaisyBill’s OMFS Calculator to INSTANTLY determine the new reimbursement amounts.
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Physician Services: Conversion Factors
On April 4th, the DWC retroactively adopted the 2016 Relative Value Unit (RVU) budget neutrality adjustment factors for dates of service on or after April 1st, 2016. These neutrality adjustment factors alter the Conversion Factors necessary for calculating reimbursements. As of April 1, 2016, the new Conversion Factors MUST be applied to every reimbursement calculation.
To access the updated Conversion Factors:
- Open DWC Regulations.
- Scroll down to page 75, which is part of the Update Table, Subsection c.
- Find the section labeled “Conversion Factors adjusted for MEI and Relative Value Scale adjustment factor.”
- View the new conversion factors for April 1, 2016.
For your convenience, the updated conversion factors are listed in the table below.
Conversion Factors Adjusted for MEI and RVU: On or After April 1, 2016
All other services
To learn how to apply the new conversion factors to calculate reimbursements, read DaisyBill’s Work Comp FAQs:
- § 9789.12.5 Conversion Factors
- § 9789.12.2 Calculation of the Maximum Reasonable Fee - Services Other than Anesthesia
Physician Services: Updates to MUEs, PTP Edits, and RVU File
The DWC also updated the Physician’s Fee schedule by adopted the following Medicare quarterly updates:
- National Correct Coding Initiative Medically Unlikely Edits:
- Navigate to the Medically Unlikely Edits section of the DWC website and download the January/April 2016 MUE file.
- National Correct Coding Initiative Physician/Practitioner Services CCI Edits:
- At the bottom of the cms.gov webpage on PTP Coding Edits, download the appropriate file(s) for April 1, 2016.
- CMS’ Medicare National Physician Fee Schedule Relative Value File (RVU file) RVU16B:
- Open DWC Regulations.
- Scroll down to pages 74 - 75, which is part of the Update Table, Subsection c.
- Toward the bottom, find the section labeled “CMS’ Medicare National Physician Fee Schedule Relative Value File [Zip].”
- Find the April 1, 2016 update and download the RVU16B file.
DMEPOS: New Rural ZIP Code File
For dates of service on or after April 1st, 2016, the DWC updated the DMEPOS fee schedule to reflect Medicare changes to the payment system. Effective immediately, the April 2016 DMEPOS Rural ZIP code file replaces the January 2016 DMEPOS Rural ZIP code file for all services rendered on or after April 1st, 2016.
To access the updated fee schedule files to determine new reimbursement amounts:
- Download the “DME16-B [ZIP, 283KB]” file from the CMS.gov website.
For more information on all of these changes, see:
Free Webinar: Request for Second Review (SBR)
Billing and payment mistakes are inevitable whenever fees and fee factors change (which happens at least every quarter). Request for Second Review is the only way to appeal an incorrect payment for work comp services.
Learn how to effectively submit and how to compliantly process a Second Review by watching DaisyBill’s free SBR webinar.