DAR File No. 39832

Labor Commission, Industrial Accidents

Section R612-300-4

General Method For Computing Medical Fees

Notice of Proposed Rule

(Amendment)

DAR File No.: 39832
Filed: 10/15/2015 03:06:18 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this amendment is to adopt, with modifications, the Optum 2015 Essential Resource-Based Relative Value Schedule (RBRVS), 2015 1st Quarter Emergency Update and to specify the effective date of the rule as being 12/01/2015.

Summary of the rule or change:

The proposed rule simply updates the incorporated material to the most current edition.

State statutory or constitutional authorization for this rule:

• Section 34A-2-201
• Section 34A-1-104 et seq.

This rule or change incorporates by reference the following material:

• Updates The Essential RBRVS, published by Optum, 2015
• Updates Current Procedural Coding Expert, published by Optum, 2015

Anticipated cost or savings to:

the state budget:

Updating the referenced source material provides no impact to the state budget.

local governments:

Updating the referenced source material provides no impact to the local government.

small businesses:

Updating the referenced source material provides no impact to small businesses.

persons other than small businesses, businesses, or local governmental entities:

Updating the referenced source material provides no impact to persons other than small businesses, businesses, or local government entities.

Compliance costs for affected persons:

Updating the referenced source material provides no impact to affected persons.

Comments by the department head on the fiscal impact the rule may have on businesses:

Updating the referenced source material provides no fiscal impact.

Sherrie Hayashi, Commissioner

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Labor Commission
Industrial Accidents
HEBER M WELLS BLDG
160 E 300 S
SALT LAKE CITY, UT 84111-2316

Direct questions regarding this rule to:

• Ron Dressler at the above address, by phone at 801-530-6841, by FAX at 801-530-6804, or by Internet E-mail at rdressler@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

12/01/2015

This rule may become effective on:

12/08/2015

Authorized by:

Sherrie Hayashi, Commissioner

R612. Labor Commission, Industrial Accidents.

R612-300. Workers' Compensation Rules - Medical Care.

R612-300-4. General Method For Computing Medical Fees.

A. Adoption of "CPT" and "RBRVS." The Labor Commission hereby adopts and by this reference incorporates:

"Optum 201[4]5 The Essential RBRVS, 201[4]5 1st Quarter Emergency Update," designated as 1761/RBRCU/U177[1]9R--RBRC1[3]5/RBRC/U177[1]9R, ("RBRVS" hereafter).

B. Medical fees calculated according to the RBRVS relative value unit assigned to each CPT code. Unless some other provision of these rules specifies a different method, the RBRVS is to be used in conjunction with the "conversion factors" established in subsection C. of this rule to calculate payments for medical care provided to injured workers.

C. Conversion Factors. Fees for medical care of injured workers shall be computed by determining the relative value unit ("RVU") assigned by the RBRVS to a CPT code and then multiplying that RVU by the following conversion factors for specific medical specialties:

1. Anesthesiology (1 unit per 15 minutes of anesthesia): $53.00;

2. Medicine (Evaluation and Medicine Codes 99201 - 99204 and 99211-99214): $50.00;

3. Pathology and Laboratory: $56.00;

4. Radiology: $58.00;

5. Restorative Services: $50.00;

6. Surgery (all 20000 codes, codes 49505 thru 49525, and all 60000 codes): $62.00;

7. Other Surgery: $40.00.

D. Fees for Medical care not addressed by CPT/RBRVS, or requiring unusual treatment.

1. The payor and medical provider may establish and agree to a reasonable fee for medical care of an injured worker if:

a. neither the CPT/RBRVS or any other provision of these rules address the medical care in question; or

b. application of CPT/RBRVS or other provisions of these rules would result in an inadequate fee due to extraordinary difficulty of treatment.

2. If the medical provider and payor cannot agree to a reasonable fee in such cases, the provider can request a hearing before the Commission's Adjudication Division to establish a reasonable fee.

 

KEY: workers' compensation, fees, medical practitioners

Date of Enactment or Last Substantive Amendment: [November 24, 2014]2015

Authorizing, and Implemented or Interpreted Law: 34A-1-104; 34A-2-201