DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS · DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS ......

1

DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS

Amendments to Chapter 12-15

Hawaii Administrative Rules

Workers’ Compensation

Relating to Medical Fee Schedule

August 23, 2017

1. Section 12-15-32, Hawaii Administrative

Rules, is amended to read as follows:

"§12-15-32 Physicians. (a) Frequency and extent of

treatment shall not be more than the nature of the injury

and the process of a recovery requires. Authorization is

not required for the initial fifteen treatments of the

injury during the first sixty calendar days.

(b) If the physician believes treatments in addition

to that allowed by subsection (a) are required, the

physician shall [mail] transmit a treatment plan to the

employer by mail or facsimile under separate cover at

least seven calendar days prior to the start of the

additional treatments to an address or facsimile number

provided by the employer. A treatment plan shall be for

one hundred twenty calendar days and shall not exceed

fifteen treatments within that period. Treatments

provided with less than seven calendar days notice are

not authorized. A complete treatment plan shall contain

the following elements:

(1) Projected commencement and termination

dates of treatment;

(2) A clear statement as to the impression or

diagnosis;

(3) A specific time schedule of measurable

objectives to include baseline measurements

at the start of the treatment plan and

projected goals by the end of the treatment

plan;

(4) Number and frequency of treatments;

(5) Modalities and procedures to be used; and

(6) An estimated total cost of services.

2

Treatment plans which do not include the above specified

elements but which are reasonable and necessary may not

be denied by the employer, but upon written notification

from the employer, the physician shall correct the

deficiency(s) and the employer’s liability is deferred as

long as the treatment plan remains deficient. Neither the

injured employee nor the employer shall be liable for

services provided under a treatment plan that remains

deficient. Both the front page of the treatment plan and

the envelope in which the plan is mailed or the cover

sheet if the plan is sent by facsimile shall be clearly

identified as a “WORKERS’ COMPENSATION TREATMENT PLAN” in

capital letters and in no less than ten point type.

(c) A treatment plan shall be deemed received by an

employer when the plan is sent by mail or facsimile with

reasonable evidence showing that the treatment plan was

received.

[(c)](d) The employer may file an objection to the

treatment plan with documentary evidence supporting the

denial and a copy of the denied treatment plan with the

director, copying the physician and the injured employee.

Both the front page of the denial and the envelope in

which the denial is filed shall be clearly identified as

a “TREATMENT PLAN DENIAL” in capital letters and in no

less than ten point type. The employer shall be

responsible for payment for treatments provided under a

complete treatment plan until the date the objection is

filed with the director. Furthermore, the employer’s

objection letter must explicitly state that if the

attending physician or the injured employee does not

agree with the denial, they may request a review by the

director of the employer’s denial within fourteen

calendar days after postmark of the employer’s denial,

and failure to do so shall be construed as acceptance of

the employer’s denial.

[(d)](e) The attending physician or the injured

employee may request in writing that the director review

the employer’s denial of the treatment plan. The request

for review shall be filed with the director, copying the

employer, within fourteen calendar days after postmark of

the employer’s denial. A copy of the denied treatment

plan shall be submitted with the request for review. Both

the front page of the request for review and the envelope

in which the request is filed shall be clearly identified

3

as a “REQUEST FOR REVIEW OF TREATMENT PLAN DENIAL” in

capital letters and in no less than ten point type. For

cases not under the jurisdiction of the director at the

time of the request, the injured employee shall be

responsible to have the case remanded to the director’s

jurisdiction. Failure to file a request for review of the

employer’s denial with the director within fourteen

calendar days after postmark of the employer’s denial

shall be deemed acceptance of the employer’s denial.

[(e)](f) The director shall issue a decision, after

a hearing, either requiring the employer to pay the

physician within thirty-one calendar days in accordance

with the medical fee schedule if the treatments are

determined to be reasonable and necessary or disallowing

the fees for treatments determined to be unreasonable or

unnecessary. Disallowed fees shall not be charged to the

injured employee.

[(f)](g) The decision issued pursuant to subsection

[(e)](f) shall be final unless appealed pursuant to

section 386-87, HRS. The appeal shall not stay the

director’s decision.

[(g)](h) The psychiatric evaluation or psychological

testing with the resultant reports shall be limited to

four hours unless the physician submits prior

documentation indicating the necessity for more time and

receives pre-authorization from the employer. Fees shall

be calculated on an hourly basis as allowed under

Medicare.

[(h)](i) For physical medicine, treatments may

include up to four procedures, up to four modalities, or

a combination of up to four procedures and modalities,

and the visit shall not exceed sixty minutes per injury.

When treating more than one injury, treatments may

include up to six procedures, up to six modalities, or a

combination of up to six procedures and modalities, and

the entire visit shall not exceed ninety minutes.

[(i)](j) Any physician who exceeds the treatment

guidelines without proper authorization shall not be

compensated for the unauthorized services.

[(j)](k) No compensation shall be allowed for

preparing treatment plans and written justification for

treatments which exceed the guidelines.

4

[(k)](l) Failure to comply with the requirements in

this section may result in denial of fees.

[(l)](m) Treatment, prescribed on an in-patient

basis in a licensed acute care hospital where the injured

employee’s level of care is medically appropriate for an

acute setting as determined by community standards, are

excluded from the frequency of treatment guidelines

specified herein." [Eff 1/1/96; am 1/1/97; am

] (Auth: HRS §§386-21, 386-21.2, 386-26, 386-72) (Imp:

HRS §§386-21, 386-21.2, 386-26, 386-27)



"§12-15-34 Providers of service other than

physicians. (a) Frequency and extent of treatment shall

not be more than the nature of the injury and the process

of a recovery require. Any health care treatment or

service performed by a Hawaii licensed or certified

provider of service other than a physician shall be

directed by the attending physician based on a written

prescription signed, dated, and approved by the attending

physician. The prescription may authorize up to an

initial fifteen treatments of the injury during the first

sixty calendar days. For therapists, the prescription may

authorize up to an initial twenty treatments of the

injury during the first sixty calendar days.

(b) If the attending physician believes treatments

in addition to that allowed by subsection (a) are

required, the provider of service other than a physician,

in lieu of the attending physician, may [mail] transmit a

treatment plan for review and approval to the attending

physician who shall, after approval, [mail] transmit the

treatment plan to the employer by mail or facsimile under

separate cover at least seven calendar days prior to the

start of the additional treatments to an address or

facsimile number provided by the employer. A treatment

plan shall be for one hundred twenty calendar days and

shall not exceed fifteen treatments within that period.

Treatments provided with less than seven calendar days

notice are not authorized. A complete treatment plan

shall contain the following elements:

5

(1) Projected commencement and termination

dates of treatment;

(2) A clear statement as to the impression or

diagnosis;

(3) A specific time schedule of measurable

objectives to include baseline measurements

at the start of the treatment plan and

projected goals by the end of the treatment

plan;

(4) Number and frequency of treatments;

(5) Modalities and procedures to be used; and

Treatment plans which do not include the above specified

elements but which are reasonable and necessary may not

be denied by the employer, but upon written notification

from the employer, the physician or the provider of

service, with approval by the attending physician, shall

correct the deficiency(s) and the employer’s liability is

deferred as long as the treatment plan remains deficient.

Neither the injured employee nor the employer shall be

liable for services provided under a treatment plan that

remains deficient. Both the front page of the treatment

plan and the envelope in which the plan is mailed or the

cover sheet if the plan is sent by facsimile shall be

clearly identified as a “WORKERS’ COMPENSATION TREATMENT

PLAN” in capital letters and in no less than ten point

type.

(c) A treatment plan shall be deemed received by an

employer when the plan is sent by mail or facsimile with

reasonable evidence showing that the treatment plan was

received.

[(c)](d) The employer may file an objection to the

treatment plan with documentary evidence supporting the

denial and a copy of the denied treatment plan with the

director, copying the attending physician, the provider

of service and the injured employee. Both the front page

of the denial and the envelope in which the denial is

filed shall be clearly identified as a “TREATMENT PLAN

DENIAL” in capital letters and in no less than ten point

type. The employer shall be responsible for payment for

treatments provided under a complete treatment plan until

the date the objection is filed with the director.

Furthermore, the employer’s objection letter must

explicitly state that if the attending physician or the

6

injured employee does not agree with the denial, they may

request a review by the director of the employer’s denial

within fourteen calendar days after postmark of the

employer’s denial, and failure to do so shall be

construed as acceptance of the employer’s denial.

[(d)](e) The attending physician or the injured

employee may request in writing that the director review

the employer’s denial of the treatment plan. The request

for review shall be filed with the director, copying the

employer, within fourteen calendar days after postmark of

the employer’s denial. A copy of the denied treatment

plan shall be submitted with the request for review. Both

the front page of the request for review and the envelope

in which the request is filed shall be clearly identified

as a “REQUEST FOR REVIEW OF TREATMENT PLAN DENIAL” in

capital letters and in no less than ten point type. For

cases not under the jurisdiction of the director at the

time of the request, the injured employee shall be

responsible to have the case remanded to the director’s

jurisdiction. Failure to file a request for review of the

employer’s denial with the director within fourteen

calendar days after postmark of the employer’s denial

shall be deemed acceptance of the employer’s denial.

[(e)](f) The director shall issue a decision, after

a hearing, either requiring the employer to pay the

provider of service other than a physician within thirty-

one calendar days in accordance with the medical fee

schedule if the treatments are determined to be

reasonable and necessary or disallowing the fees for

treatments determined to be unreasonable or unnecessary.

Disallowed fees shall not be charged to the injured

employee.

[(f)](g) The decision issued pursuant to subsection

[(e)](f) shall be final unless appealed pursuant to

section 386-87, HRS. The appeal shall not stay the

director’s decision.

[(g)](h) The provider of service other than a

physician shall submit reports at least monthly to the

attending physician and employer regarding an injured

employee’s progress. The preparation and submission of

written reports or progress notes to the employer by the

provider of service other than a physician are an

integral part of the service fee.

7

[(h)](i) Treatments may include up to four

procedures, up to four modalities, or a combination of up

to four procedures and modalities, and the visit shall

not exceed sixty minutes per injury. When treating more

than one injury, treatments may include up to six

procedures, up to six modalities, or a combination of up

to six procedures and modalities, and the entire visit

shall not exceed ninety minutes. This section applies to

providers of service other than physicians including

physical therapists, occupational therapists, massage

therapists, and acupuncturists.

[(i)](j) Any provider of service other than a

physician who exceeds the treatment guidelines without

proper authorization shall not be compensated for the

unauthorized services.

[(j)](k) No compensation shall be allowed for

preparing treatment plans and written justification for

treatments which exceed the guidelines.

[(k)](l) Failure to comply with the requirements in

this section may result in denial of fees.

[(l)](m) Therapy by physical therapists and

occupational therapists, prescribed on an in-patient

basis in a licensed acute care hospital where the injured

employee’s level of care is medically appropriate for an

acute setting as determined by community standards or,

prescribed on an out-patient post-surgery basis not to

exceed thirty calendar days, are excluded from the

frequency of treatment guidelines specified herein."

[Eff 1/1/96; am 1/1/97; am ] (Auth:

HRS §§386-21, 386-21.2, 386-26, 386-72) (Imp: HRS §§386-

21, 386-21.2, 386-26, 386-27)



“§12-15-90 Workers’ compensation medical fee

schedule. (a) Charges for medical services shall not

exceed one hundred ten per cent of participating fees

prescribed in the Medicare Resource Based Relative

Value Scale System fee schedule (Medicare Fee

Schedule) applicable to Hawaii or listed in exhibit A,

located at the end of this chapter and made a part of

this chapter, entitled “Workers’ Compensation

8

Supplemental Medical Fee Schedule”, dated [January 1,

2014] January 1, 2018. The Medicare Fee Schedule in

effect on January 1, 1995 shall be applicable through

June 30, 1996. Beginning July 1, 1996 and each

calendar year thereafter, the Medicare Fee Schedule in

effect as of January 1 of that year shall be the

effective fee schedule for that calendar year.

(b) If maximum allowable fees for medical

services are listed in both the Medicare Fee Schedule

and the Workers’ Compensation Supplemental Medical Fee

Schedule, dated [January 1, 2014] January 1, 2018,

located at the end of this chapter as exhibit A,

charges shall not exceed the maximum allowable fees

allowed under the Workers’ Compensation Supplemental

Medical Fee Schedule, dated [January 1, 2014]

January 1, 2018, located at the end of this chapter as

exhibit A.

(c) If the charges are not listed in the

Medicare Fee Schedule or in the Workers’ Compensation

Supplemental Medical Fee Schedule, dated [January 1,

2014] January 1, 2018, located at the end of this

chapter as exhibit A, the provider of service shall

charge a fee not to exceed the lowest fee received by

the provider of service for the same service rendered

to private patients. Upon request by the director or

the employer, a provider of service shall submit a

statement to the requesting party, itemizing the

lowest fee received for the same health care,

services, and supplies furnished to any private

patient during the one-year period preceding the date

of a particular charge. Requests shall be submitted

in writing within twenty calendar days of receipt of a

questionable charge. The provider of service shall

reply in writing within thirty-one calendar days of

receipt of the request. Failure to comply with the

request of the employer or the director shall be

reason for the employer or the director to deny

payment.

(d) Fees listed in the Medicare Fee Schedule

shall be subject to the current Medicare Fee Schedule

bundling and global rules if not specifically

addressed in these rules. The Health Care Financing

9

Administration Common Procedure Coding System (HCPCS)

alphabet codes adopted by Medicare will not be

allowed, except for injections and durable medical

equipment, unless specifically adopted by the

director. The director may defer to a fee listed in

the Medicare HCPCS Fee Schedule when a fee is not

listed in the Workers’ Compensation Supplemental

Medical Fee Schedule, Exhibit A.

(e) Providers of service will be allowed to add

the applicable Hawaii general excise tax to their

billing.” [Eff 1/1/96; am 1/1/97; am 11/22/97;

am 12/17/01; am 12/13/04; am 11/6/06; am 12/14/07; am

2/28/11; am 12/30/13; am ] (Auth:

HRS §§386-21, 386-26, 386-72) (Imp: HRS §§386-21,

386-26)

10

4. Material, except source notes, to be

repealed is bracketed. New material is underscored.

5. Additions to update source notes to reflect

these amendments are not underscored.

6. These amendments to Title 12, Chapter 15,

Hawaii Administrative Rules, relating to the Hawaii

Workersꞌ Compensation Medical Fee Schedule shall take

effect ten days after filing with the Office of the

Lieutenant Governor.

I certify that the foregoing are copies of the

rules drafted in the Ramseyer format, pursuant to the

requirements of section 91-4.1, Hawaii Revised

Statutes, which were adopted on (date to be inserted

upon adoption) and filed with the Office of the

Lieutenant Governor.

____________________________

Director

APPROVED AS TO FORM:

__________________________

Deputy Attorney General

CPT only copyright 2016 American Medical Association. CDT copyright 2016 American Dental Association. AllRights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

A-1

EXHIBIT A

Chapters 12-15Hawaii Administrative Rules

WORKERS’ COMPENSATION SUPPLEMENTALMEDICAL FEE SCHEDULE

January 1, 2018

The codes in the Workers’ Compensation Supplemental Medical Fee Schedule are obtained fromthe American Medical Association, the American Dental Association or the State Department ofLabor and Industrial Relations.

The five character codes included in the Workers’ Compensation Supplemental Medical FeeSchedule are obtained from 2017 Current Procedural Terminology (CPT®), copyright 2016 by theAmerican Medical Association (AMA). CPT is developed by the AMA as a listing of descriptiveterms and five character identifying codes and modifiers for reporting medical services andprocedures performed by physicians.

The responsibility for the content of the Workers’ Compensation Supplemental Medical FeeSchedule is with DLIR and no endorsement by the AMA is intended or should be implied. TheAMA disclaims responsibility for any consequences or liability attributable or related to any use,nonuse or interpretation of information contained in the Workers’ Compensation SupplementalMedical Fee Schedule. Fee schedules, relative value units, conversion factors and/or relatedcomponents are not assigned by the AMA, are not part of CPT, and the AMA is not recommendingtheir use. The AMA does not directly or indirectly practice medicine or dispense medical services.The AMA assumes no liability for data contained or not contained herein. Any use of CPT outsideof the Workers’ Compensation Supplemental Medical Fee Schedule should refer to the most currentCPT codes and descriptive terms. Applicable FARS/DFARS apply.

CPT is a registered trademark of the American Medical Association

The five character codes starting with the letter “D” included in the Workers’ CompensationSupplemental Medical Fee Schedule are obtained from Current Dental Terminology 2017,copyright 2016 by the American Dental Association (ADA). CDT is developed by the ADA toachieve uniformity, consistency and accurate reporting of dental treatment.


A-2

TABLE OF CONTENTS

TITLE CODES PAGESURGERY

Integumentary System 10060-17004 A-4Musculoskeletal System 20520-29916 A-4Respiratory System 31231-32551 A-6Cardiovascular System 35206-36620 A-6Digestive System 45378-49653 A-6Urinary System 51700, 51798 A-6Male Genital System 55520 A-6Female Genital System 57288 A-6Maternity Care and Delivery 59025 A-6Nervous System 62270-64856 A-6Eye and Ocular Adnexa 65205-68815 A-7Auditory System 69200, 69210 A-7Operating Microscope 69990 A-7

RADIOLOGYDiagnostic Radiology (Diagnostic Imaging) 70030-76377 A-7Diagnostic Ultrasound 76512-76942 A-8Radiologic Guidance 77001, 77012 A-8Bone/Joint Studies 77073, 77080 A-8Radiation Oncology 77290-77336 A-8Nuclear Medicine 78104-78806 A-8

MEDICINEVaccines, Toxoids 90636-90746 A-9Psychiatry 90791-90847 A-9Biofeedback 90901 A-9Gastroenterology 91035, 91110 A-9Ophthalmology 92002-92310 A-9Special Otorhinolaryngologic Services 92507-92611 A-9Cardiovascular 93000-93351 A-9Noninvasive Vascular Diagnostic Studies 93926-93976 A-10Pulmonary 94010-94762 A-10Neurology and Neuromuscular Procedures 95805-95972 A-10Central Nervous System Assessments/Tests 96101 A-10Health and Behavior Assessment/Intervention 96150, 96152 A-10Hydration, Therapeutic, Prophylactic, Diagnostic

Injections and Infusions, and Chemotherapy andOther Highly Complex Drug or Highly ComplexBiologic Agent Administration 96360-96376 A-10

Physical Medicine and Rehabilitation 97010-97760 A-10Acupuncture 97810-97814 A-10Chiropractic Manipulative Treatment 98940 A-10Special Services, Procedures and Reports 99000-99053 A-11Qualifying Circumstances for Anesthesia 99100 A-11Other Services and Procedures 99173, 99183 A-11


A-3

TITLE CODES PAGEDENTAL SERVICES

Diagnostic D0120-D0470 A-11Preventive D1110 A-11Restorative D2160-D2954 A-11Endodontics D3310 A-11Periodontics D4211 A-11Prosthodontics, Removable D5110-D5820 A-11Implant Services D6010-D6104 A-11Prosthodontics, Fixed D6240-D6750 A-11Oral and Maxillofacial Surgery D7140-D7953 A-12Adjunctive General Services D9110-D9942 A-12

EVALUATION AND MANAGEMENTOffice or Other Outpatient Services 99201-99215 A-12Hospital Inpatient Services 99232 A-12Consultations 99241-99255 A-12Emergency Department Services 99281-99285 A-12Critical Care Services 99292 A-12Case Management Services 99366-99368 A-12Preventive Medicine Services 99395, 99408 A-12Non-Face-to-Face Services 99441-99443 A-12Special Evaluation and Management Services 99456A, 99456B A-13


A-4

SURGERY

Integumentary System

Maximum Maximum MaximumCode Fee Code Fee Code Fee

10060 $157.6410061 $275.0310120 $207.9510121 $389.0611000 $77.1411001 $30.1911010 $704.3411043 $311.9211044 $435.7111055 $61.9311056 $74.4711601 $280.4811602 $309.4811719 $17.8511730 $144.2211740 $73.7911750 $335.4011760 $315.2812001 $177.2512002 $188.5512004 $214.6612005 $268.32

12007 $362.2312011 $189.7012013 $209.9012014 $234.7812015 $285.0912031 $365.5912032 $486.3312034 $472.9112035 $550.0612041 $352.1712042 $456.1412044 $533.2912051 $385.7112052 $432.6712053 $526.5812054 $566.8313100 $446.0813101 $603.7213121 $630.5513122 $167.7013131 $513.1613132 $818.38

13133 $231.4313151 $613.7813152 $791.5413153 $254.9013160 $980.0114040 $1,120.2415004 $478.2615050 $675.4815100 $1,021.3815101 $223.2715120 $1,136.5815240 $1,119.9715260 $1,428.8015738 $1,716.0616000 $93.9116020 $114.0416025 $201.2416030 $244.8417003 $11.5717004 $190.91

Musculoskeletal System

20520 $275.0320525 $741.2320526 $90.5620550 $80.5020551 $80.5020552 $73.7920553 $83.8520600 $77.1420605 $90.5620610 $103.9720612 $73.7920900 $653.3320902 $611.9120924 $647.6720926 $522.8620930 $230.3020931 $132.3720936 $212.9620937 $228.0721310 $177.7621320 $402.4821360 $673.0421365 $1,369.0521390 $989.2721395 $1,232.63

21407 $804.0321408 $1,105.8021423 $981.3021470 $1,492.0522551 $2,623.2522552 $575.1722554 $1,846.2422558 $2,143.2122585 $480.1722600 $1,612.6722612 $2,015.7522614 $523.2222630 $1,947.7822632 $380.0722633 $2,224.8022634 $589.9522830 $988.3822840 $975.6522842 $1,076.6322845 $1,072.2722849 $1,565.0122850 $879.7122852 $843.5122856 $1,961.7923120 $722.81

23130 $771.7223350 $181.1223405 $765.1423410 $1,204.0923412 $1,203.4223420 $1,425.4523430 $1,056.5123440 $924.0823455 $1,428.8023500 $274.6623552 $805.5923570 $288.4223620 $327.1423650 $415.9023655 $586.9523700 $241.7424149 $1,445.4024305 $712.8224340 $755.2424341 $1,113.5324342 $1,044.4724343 $896.2224344 $1,337.4024357 $607.0724358 $707.69



A-5

24359 $882.1024366 $836.0224515 $1,075.7524600 $496.3924605 $707.6924665 $807.1124666 $933.5324685 $807.8225000 $494.6325024 $950.4425105 $598.1025111 $440.3425118 $501.8225240 $532.0025246 $204.8025260 $910.3325270 $734.9225272 $816.4325290 $541.3925295 $648.4925310 $765.8325320 $1,221.8925337 $1,101.2925390 $946.9525400 $985.6225405 $1,268.4625440 $945.8625447 $1,021.8125505 $768.0725545 $841.6425605 $828.4425606 $819.2625607 $922.9725608 $1,094.2725609 $1,327.4725628 $925.7425645 $728.4925825 $969.3126020 $539.7126035 $1,052.6426055 $788.1926075 $405.1726080 $486.9226105 $415.2626110 $402.1526115 $705.0126145 $634.3426320 $439.7326340 $432.6726350 $1,026.3226356 $1,703.8326410 $811.6726418 $831.7926426 $768.1626433 $664.4326440 $780.7426445 $730.0026480 $943.7926525 $820.0826540 $942.47

26541 $990.8426548 $964.8726560 $724.9226567 $843.4126600 $409.1926605 $390.0926608 $604.4226686 $766.5726720 $292.0326725 $466.2126727 $670.8026735 $868.6926742 $440.8626750 $258.2626756 $521.8726765 $684.2226770 $368.9426860 $709.9826951 $812.4226952 $802.2427096 $308.5727130 $2,049.2927216 $1,306.3027227 $2,020.0127228 $2,290.9727235 $1,161.2027236 $1,460.7927245 $1,843.4327248 $972.9527350 $801.0927370 $200.5427380 $754.0027385 $811.6727403 $786.0227405 $860.7827427 $872.9627446 $1,412.6927447 $2,190.1627457 $1,154.9927486 $1,715.4727487 $2,259.1827506 $1,891.6627524 $1,069.9327530 $482.7227535 $1,157.1327536 $1,452.5427560 $435.2427570 $198.8227603 $741.2327625 $713.9427640 $1,021.3827650 $972.6627652 $931.7927658 $463.5127675 $605.3327680 $562.2027687 $562.3827691 $923.0827695 $591.5027698 $842.56

27724 $1,536.8927750 $422.9027758 $1,091.9227759 $1,301.3527760 $400.9627766 $812.3827786 $383.9527792 $932.4127810 $572.2127814 $1,116.8827823 $1,279.5627827 $1,436.5627828 $1,677.5427840 $455.4527842 $608.2227870 $1,260.5328002 $562.9428008 $534.8128090 $583.3328122 $769.7928222 $628.8628238 $818.8828300 $801.6428400 $303.9428415 $1,382.8828445 $1,423.6728475 $318.4928485 $623.8428510 $154.6028725 $960.1828730 $905.2729065 $140.8729075 $127.4529105 $127.4529125 $100.6229130 $60.3729200 $37.7629240 $35.8429260 $35.8829280 $36.1029405 $120.7429425 $124.1029445 $168.0129515 $103.9729520 $39.6829530 $35.8429540 $32.2729550 $23.8029580 $64.0329581 $82.8829584 $93.2429700 $78.9729806 $1,509.3029807 $1,472.4129820 $707.6929821 $778.1329822 $751.3029823 $895.5229824 $859.1429825 $747.56



A-6

29826 $297.0029827 $1,517.7229828 $1,304.7129835 $620.5529837 $647.0729838 $754.4729844 $636.2429846 $665.8529848 $644.7829862 $996.5129867 $1,623.86

29873 $686.8829874 $700.1329875 $670.7529876 $832.9229877 $885.4629879 $942.4729880 $960.0129881 $896.8529882 $929.5229884 $788.0229887 $910.84

29888 $1,401.9729891 $829.7929897 $620.4129898 $746.8529905 $837.8629906 $853.6529914 $1,219.8729915 $1,243.1429916 $1,244.58

Respiratory System

31231 $295.1531240 $195.12

31570 $408.3231575 $139.42

32551 $187.59

Cardiovascular System

35206 $930.9935207 $962.3836245 $1,676.0036246 $1,063.21

36247 $1,969.1336410 $23.7636415 $4.3436430 $46.91

36569 $321.5836600 $40.2536620 $60.85

Digestive System

45378 $516.2349505 $670.3849507 $704.1149520 $774.5849560 $884.14

49568 $315.2649585 $545.8049587 $574.6849650 $528.3649651 $672.45

49652 $891.8449653 $1,111.71

Urinary System

51700 $93.90 51798 $25.86

Male Genital System

55520 $550.26

Female Genital System

57288 $869.84

Maternity Care and Delivery

59025 $59.78

Nervous System

62270 $202.8662362 $469.4062368 $70.7662369 $154.9562370 $162.3663030 $1,368.4363035 $271.6763042 $1,654.9863045 $1,545.83

63047 $1,560.2463048 $301.6363075 $1,949.9463655 $1,002.5863663 $997.1963685 $446.5063688 $453.2664405 $129.3864415 $146.81

64421 $189.6064445 $164.7964450 $147.5864455 $59.0064479 $299.2264480 $142.3664483 $345.4664484 $187.8264491 $113.76



A-7

64492 $115.2564495 $104.6964510 $163.3364520 $236.0864550 $23.4864616 $153.3664617 $222.6864633 $536.70

64634 $243.7264635 $531.0864636 $222.2164640 $169.4164646 $182.6364702 $622.4364704 $448.2264708 $601.10

64718 $805.7964721 $607.0764772 $691.0364776 $505.5264782 $561.6964831 $906.9764832 $410.1564856 $1,236.90

Eye and Ocular Adnexa

65205 $80.5065210 $97.2765222 $100.6265426 $972.6665430 $137.61

65435 $107.3367036 $1,125.8867145 $650.5467820 $62.5667917 $767.01

68720 $946.8468810 $200.7168815 $514.53

Auditory System

69200 $191.18 69210 $73.79

Operating Microscope

69990 $305.21

RADIOLOGY

Fees include both the technical and professional components. In the absence of any prior agreement, the professionalcomponent shall be thirty-five percent of the scheduled fee.

Diagnostic Radiology (Diagnostic Imaging)

70030 $40.2570100 $46.9670110 $57.0270140 $46.9670150 $67.0870160 $46.9670200 $67.0870220 $63.7370250 $53.6670260 $77.1470330 $70.4370336 $673.5570355 $40.2570360 $40.2570450 $345.4670470 $529.9370480 $368.3970486 $181.3070488 $590.3070491 $486.3370496 $382.3870498 $381.4170540 $656.5570543 $545.8770544 $660.51

70547 $740.7470548 $730.7270551 $300.5570553 $492.1571010 $40.2571020 $50.3171035 $50.3171100 $50.3171101 $60.3771110 $63.7371111 $80.5071120 $53.6671130 $57.0271250 $425.9671260 $523.2271270 $637.2671275 $391.5071550 $669.5471552 $1,210.7472020 $36.8972040 $53.6672050 $77.1472052 $97.2772070 $53.6672072 $60.37

72074 $70.4372080 $57.0272100 $57.0272110 $80.5072114 $103.9772120 $73.7972125 $409.1972128 $409.1972131 $409.1972132 $523.2272133 $623.8472141 $291.7272142 $425.2472146 $292.1972148 $290.7672149 $420.2272156 $495.5072157 $496.4572158 $493.5772170 $43.6072190 $57.0272192 $405.8372193 $506.4572195 $670.3072197 $665.03



A-8

72200 $43.6072202 $53.6672220 $46.9672265 $264.9772275 $171.0572295 $385.7173000 $43.6073010 $43.6073020 $36.8973030 $46.9673040 $167.7073050 $54.0873060 $46.9673070 $40.5173080 $50.3173090 $43.6073100 $43.6073110 $50.3173115 $147.5873120 $40.2573130 $46.9673200 $382.3673201 $479.6273218 $656.66

73220 $658.2873221 $309.7673222 $497.7373223 $618.1073525 $157.6473560 $43.6073562 $50.3173564 $57.0273565 $44.9773580 $194.5373590 $43.6073600 $40.2573610 $46.9673620 $40.2573630 $46.9673650 $40.2573660 $40.2573700 $382.3673701 $479.6273706 $465.1673718 $567.9973720 $661.6373721 $309.2873722 $502.05

73723 $618.5974000 $43.6074020 $60.3774022 $70.4374150 $405.8374160 $533.2974175 $400.5974176 $258.2874178 $461.8374181 $669.8974183 $666.4675635 $849.8975710 $643.9775716 $677.5175736 $643.9775774 $560.1276000 $62.3676001 $211.3076100 $118.8976376 $29.8776377 $90.31

Diagnostic Ultrasound

76512 $164.5576513 $150.9376514 $19.0676519 $122.7176700 $197.8976705 $147.5876770 $187.82

76775 $150.9376801 $160.5876815 $110.5476817 $126.9276856 $167.7076857 $61.4976870 $167.70

76881 $151.1076882 $43.4976937 $40.2476942 $76.68

Radiologic Guidance

77001 $110.55 77012 $158.81

Bone/Joint Studies

77073 $45.95 77080 $53.78

Radiation Oncology

77290 $674.15 77334 $264.97 77336 $140.87

Nuclear Medicine

78104 $348.8278122 $258.2678300 $234.78

78305 $318.6378306 $355.5278320 $415.90

78452 $646.2978805 $271.6778806 $496.39



A-9

MEDICINE

Fees include both the technical and professional components. In the absence of any prior agreement, the professionalcomponent shall be thirty-five percent of the scheduled fee.

Vaccines, Toxoids

90636 $99.0790714 $21.90

90715 $46.9690732 $86.62

90746 $63.32

Psychiatry

90791 $154.6890792 $173.7390832 $84.86

90834 $99.6990837 $167.7490846 $126.80

90847 $151.70

Biofeedback

90901 $53.27

Gastroenterology

91035 $626.61 91110 $1,217.70

Ophthalmology

92002 $110.6892004 $201.2492012 $110.6892014 $160.9992015 $23.5092020 $42.4292025 $48.21

92071 $45.4392082 $62.5792083 $83.4692132 $39.7592133 $47.7392134 $52.2192136 $115.85

92225 $34.4492235 $169.7292250 $86.0192284 $82.7192285 $27.4792286 $49.1792310 $78.69

Special Otorhinolaryngologic Services

92507 $97.3792511 $144.5192526 $106.6892541 $69.7492542 $67.0892545 $50.3992547 $23.4892548 $140.87

92550 $25.2492551 $13.5292557 $63.4092567 $26.8392570 $38.4292577 $29.6092587 $69.4392588 $96.86

92590 $74.9492591 $99.1192592 $35.5192595 $51.3392610 $106.7192611 $107.45

Cardiovascular

93000 $33.4593005 $20.1293010 $11.2193015 $135.8293016 $26.8693017 $83.8593018 $20.12

93040 $16.8493042 $10.0693224 $187.9693225 $57.0293226 $93.9193280 $73.1993282 $79.37

93289 $82.2893306 $298.7993308 $137.1593325 $80.5093351 $353.39



A-10

Noninvasive Vascular Diagnostic Studies

93926 $171.42 93971 $158.92 93976 $250.52

Pulmonary

94010 $46.8094060 $80.1494150 $47.4694640 $24.64

94645 $18.4894664 $23.2294667 $35.4494726 $69.18

94727 $54.0294729 $69.4694760 $6.7194762 $43.60

Neurology and Neuromuscular Procedures

95805 $721.2895810 $821.2195811 $862.7095851 $27.0095852 $20.1395861 $224.7295885 $87.2095887 $107.33

95907 $147.5895908 $157.6495909 $214.6695910 $285.0995911 $342.1195912 $399.1395913 $462.8595925 $182.99

95929 $277.9095930 $172.2095951 $2,089.2595957 $397.7095971 $61.9395972 $72.10

Central Nervous System Assessments/Tests

96101 $97.27

Health and Behavior Assessment/Intervention

96150 $25.59 96152 $23.15

Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions,and Chemotherapy and Other Highly Complex Drug

or Highly Complex Biologic Agent Administration

96360 $92.5896361 $24.0796365 $91.06

96366 $24.0096367 $39.9796375 $29.03

96376 $20.77

Physical Medicine and Rehabilitation

97010 $5.0497012 $20.1297014 $16.7797016 $24.1597024 $8.4997032 $23.4897110 $43.6097112 $43.60

97116 $36.8997124 $33.5497140 $36.8997150 $20.6797530 $46.9697532 $32.9097535 $43.9097537 $37.31

97542 $38.3497545 $119.6997546 $51.1797605 $51.2797606 $61.7197750 $40.2597760 $50.31

Acupuncture

97810 $52.3997811 $35.31

97813 $55.9597814 $39.55

Chiropractic Manipulative Treatment

98940 $30.19



A-11

Special Services, Procedures and Reports

99000 $8.1799002 $10.89

99050 $48.2599053 $70.50

Qualifying Circumstances for Anesthesia

99100 $44.79

Other Services and Procedures

99173 $3.42 99183 $131.33

DENTAL SERVICES

Diagnostic

D0120 $41.81D0140 $52.13D0150 $57.69

D0210 $94.66D0220 $19.29D0230 $15.07

D0272 $30.96D0330 $83.69D0470 $64.96

Preventive

D1110 $68.87

Restorative

D2160 $115.71D2330 $84.86D2331 $127.28D2332 $158.31

D2335 $183.74D2391 $106.64D2740 $837.28D2750 $789.63

D2940 $73.72D2950 $179.19D2954 $204.42

Endodontics

D3310 $412.71

Periodontics

D4211 $211.85

Prosthodontics, Removable

D5110 $988.75D5130 $1,048.91

D5211 $776.37D5212 $806.73

D5820 $395.17

Implant Services

D6010 $1,712.90D6057 $566.15

D6059 $1,131.93D6065 $1,074.45

D6104 $296.69

Prosthodontics, Fixed

D6240 $752.13 D6245 $756.50 D6750 $786.07



A-12

Oral & Maxillofacial Surgery

D7140 $92.58D7210 $198.03

D7880 $490.00D7953 $307.20

Adjunctive General Services

D9110 $76.43D9310 $91.08

D9430 $55.53D9940 $408.83

D9942 $102.80

EVALUATION AND MANAGEMENT

Office or Other Outpatient Services

99201 $70.3699202 $114.0099203 $165.5599204 $245.01

99205 $304.8399211 $37.0799212 $66.3299213 $107.83

99214 $158.7799215 $212.24

Hospital Inpatient Services

99232 $124.79

Consultations

99241 $66.5899242 $99.8199243 $143.4699244 $186.63

99245 $237.1999251 $53.7699252 $83.1099253 $126.71

99254 $183.8199255 $222.85

Emergency Department Services

99281 $50.3199282 $90.19

99283 $133.0099284 $225.58

99285 $322.51

Critical Care Services

99292 $147.36

Case Management Services

99366 $65.67 99367 $85.93 99368 $55.55

Preventive Medicine Services

99395 $116.14 99408 $40.23

Non-Face-to-Face Services

99441 $22.2399442 $40.98

99443 $60.50



A-13

Special Evaluation and Management ServicesMaximum

Code Description Fee99456A* Complex consultation pursuant to Section 386-79, HRS - work related or medical disability

examination by other than the treating physician that includes: completion of a medical history commensurate with the patient’s condition; performance of an examination commensurate with the patient’s condition; formulation of a diagnosis, assessment of capabilities and stability, and calculation of

impairment; development of future medical treatment plan; completion of necessary documentation/certificates and report; and review of records relating to the patient’s condition.First hour ................................................................................................................................................... $207.25

99456B* Each additional 30 minute increment (an increment must be at least 30 minutes.) ............................. $103.63

*Department of Labor Code

Bundled Services: Certain codes, such as telephone calls, are considered by the Health Care Financing Administration (HCFA) tobe “bundled” services. Bundled services are not payable, nor should they be billed, when performed incidentto or in conjunction with another service even if the other service is performed on a different day. Whenservices that are designated as bundled are denied, the physician may not collect from the patient.

DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS · DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS ......

Documents

Transcript of DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS · DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS ......