Current through Register Vol. 63, No. 3, March 1, 2024
(1)
Fee Schedule Table.
(a) Unless
otherwise provided by contract or fee discount agreement allowed by these
rules, insurers must pay according to the following table: [See attached
table.]
(b) The global period is
listed in the column 'Global Days' of Appendix B.
(2)
Anesthesia.
(a) When using the American Society of
Anesthesiologists Relative Value Guide, a basic unit value is determined by
reference to the appropriate anesthesia code. The total anesthesia value is
made up of a basic unit value and, when applicable, time and modifying
units.
(b) Physicians or certified
nurse anesthetists may use basic unit values only when they personally
administer the general anesthesia and remain in constant attendance during the
procedure for the sole purpose of providing the general anesthesia.
(c) Attending surgeons may not add time units
to the basic unit value when administering local or regional block for
anesthesia during a procedure. The modifier 'NT' (no time) must be on the
bill.
(d) Local infiltration,
digital block, or topical anesthesia administered by the operating surgeon is
included in the payment for the surgical procedure.
(e) In calculating the units of time, use 15
minutes per unit. If a medical provider bills for a portion of 15 minutes,
round the time up to the next 15 minutes and pay one unit for the portion of
time.
(f) The maximum allowable
payment amount for anesthesia codes is determined by multiplying the anesthesia
value by a conversion factor of $60.93. Unless otherwise provided by contract
or fee discount agreement permitted by these rules, the insurer must pay the
lesser of:
(A) The maximum allowable payment
amount for anesthesia codes; or
(B)
The provider's usual fee.
(g) When the anesthesia code is designated by
IC (individual consideration), unless otherwise provided by a contract or fee
discount agreement, the insurer must pay 80 percent of the provider's usual
fee.
(h) Payment for services
billed with modifiers QY, QK, or QX is at 50 percent of the applicable fee
schedule amount.
(3)
Surgery. Unless otherwise provided by contract or fee discount
agreement permitted by these rules, insurers must pay multiple surgical
procedures performed in the same session according to the following:
(a) One surgeon [See attached
table.]
(b) Two or more surgeons
[See attached table.]
(c) Assistant
surgeons [See attached table.]
(d)
Nurse practitioners or physician assistants [See attached table.]
(e) Self-employed surgical assistants who
work under the direct control and supervision of a physician [See attached
table.]
(f) When a surgeon performs
surgery following severe trauma, and the surgeon does not think the fees should
be reduced under the multiple surgery rule, the surgeon may request special
consideration by the insurer. The surgeon must provide written documentation
and justification. Based on the documentation, the insurer may pay for each
procedure at 100 percent.
(g) If
the surgery is nonelective, the physician is entitled to payment for the
initial evaluation of the patient in addition to the global fee for the
surgical procedure(s) performed. However, the pre-operative visit for elective
surgery is included in the listed global value of the surgical procedure, even
if the pre-operative visit is more than one day before surgery.
(4)
Radiology
Services.
(a) Insurers only have to pay
for X-ray films of diagnostic quality that include a report of the findings.
Insurers will not pay for 14" x 36" lateral views.
(b) When multiple contiguous areas are
examined by computerized axial tomography (CAT) scan, computerized
tomography angiography (CTA), magnetic resonance angiography
(MRA), or magnetic resonance imaging (MRI), then the
technical component must be paid 100 percent for the first area examined and 75
percent for all subsequent areas. These reductions do not apply to the
professional component. The reductions apply to multiple studies done within
two days, unless the ordering provider provides a reasonable explanation of why
the studies needed to be done on separate days.
(5)
Pathology and Laboratory
Services.
(a) The payment amounts in
Appendix B apply only when there is direct physician involvement.
(b) Laboratory fees must be billed in
accordance with ORS 676.310. If a physician submits
a bill for laboratory services that were performed in an independent
laboratory, the bill must show the amount charged by the laboratory and any
service fee that the physician charges.
(6)
Physical Medicine and
Rehabilitation Services.
(a)
Time-based CPT® codes must be billed and paid per code according to this
table: [See attached table.]
(b)
Except for CPT® codes 97161, 97162, 97163, 97164, 97165, 97166, 97167, or
97168, payment for modalities and therapeutic procedures is limited to a total
of three separate CPT®-coded services per day for each provider, identified
by their federal tax ID number. An additional unit of time for the same
CPT® code does not count as a separate code. When a provider bills for more
than three separate CPT®-coded services per day, the insurer is required to
pay the codes that result in the highest payment to the provider.
(c) For all time-based modalities and
therapeutic procedures that require constant attendance, the chart notes must
clearly indicate the time each modality or procedure begins and the time each
modality or procedure ends or the amount of time spent providing each modality
or procedure.
(d) CPT® codes
97010 through 97028 are not payable unless they are performed in conjunction
with other procedures or modalities that require constant attendance or
knowledge and skill of the licensed medical provider.
(e) When multiple treatments are provided
simultaneously by one machine, device, or table there must be a notation on the
bill that treatments were provided simultaneously by one machine, device, or
table and there must be only one charge.
(7)
Reports.
(a) Except as otherwise provided in OAR
436-009-0060, when another medical provider, or an insurer or its
representative asks a medical provider to prepare a report, or review records
or reports, the medical provider should bill the insurer for their report or
review of the records using CPT® codes such as 99080. The bill should
include documentation of time spent reviewing the records or reports.
(b) If the insurer asks the medical service
provider to review the IME report and respond, the medical service provider
must bill for the time spent reviewing and responding using OSC D0019. The bill
should include documentation of time spent.
(8)
Nurse Practitioners and Physician
Assistants. Services provided by authorized nurse practitioners,
physician assistants, or out-of-state nurse practitioners must be paid at 85
percent of the amount calculated in section (1) of this rule.
To view attachments referenced in rule text,
click here to view
rule.
Statutory/Other Authority: ORS
656.726(4)
Statutes/Other Implemented: ORS
656.248