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Nebraska Workers' Compensation Legal Library


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RULE26
SCHEDULES OF FEES FOR MEDICAL, SURGICAL, AND HOSPITAL SERVICES

A. The following Nebraska Workers' Compensation Court fee schedules, including the instructions, ground rules, unit values, and conversion factors set out in such schedules, are hereby adopted pursuant to section 48-120(1 )(b) of the Nebraska Workers' Compensation Act. Reimbursement for medical, surgical,and hospital services provided pursuant to section 48-120 shall be in accordance with such schedules, except for services covered by the inpatient hospital fee schedules established in section 48-120.04, and except for services covered by contract pursuant to section 48-120(1 )( d).
1. Schedule of Fees for Medical Services, effective January 1, 2018.
2. Schedule of Fees for Hospitals and Ambulatory Surgical Centers, effective January 1, 2012.
3. Schedule of Fees for Implantable Medical Devices, effective January 1, 2012.
Such schedules and the inpatient hospital fee schedules established in section 48-120.04 shall be available free of charge on the court's website at http://www.wcc.ne.gov.

B.Schedule of Fees for Medical Services.
1. The Schedule of Fees for Medical Services shall apply to medical and surgical services provided by physicians and other licensed health care providers within the scope of their respective licenses.
2. Effective January 1, 2016, the Schedule of Fees for Medical Services shall be established as follows. Adjustments to the schedule shall be made annually thereafter as provided herein, with such adjustments to become effective each January 1.
a. The schedule shall include the Medicare Resource-Based Relative Value Scale (RBRVS) applicable to Nebraska, as reflected in the applicable tables established and published by the federal Centers for Medicare and Medicaid Services (CMS) for the federal Medicare program and geographically adjusted for Nebraska.
b. The schedule shall include the Current Procedural Terminology (CPT) codes in the CMS tables and the relative value units established by CMS for each CPT code in the tables.
c. The schedule shall be adjusted annually to incorporate the CPT codes and relative value units in the then current CMS tables applicable to Nebraska.
d. The schedule may be supplemented with additional CPT codes, relative value units, follow-up days, base values, instructions, ground rules, or other components or factors as determined by the court.
e. The conversion factors and service categories of the schedule shall be as follows:
i.. For calendar year 2016, sixty-three dollars and fifty-nine cents ($63.59) for emergency department services, fifty dollars and one cent ($50.01) for all other evaluation and management services, fifty dollars and seventy-seven cents ($50.77) for anesthesia services, one hundred and six dollars and seven cents ($106.07) for orthopedic surgery services, seventy-two dollars and twenty-two cents ($72.22) for all other surgery services, eighty-six dollars and ninety-two cents ($86.92) for radiology services, seventy-six dollars
and thirty-two cents ($76.32) for pathology and laboratory services, fifty-four dollars and thirty-six cents ($54.36) for medicine services, and forty-eight dollars and twenty-three cents
($48.23) for physical medicine services. The specific services and related CPT codes to be included in each service category shall be determined by the court.
ii. For calendar years after 2016, the conversion factors shall be determined by applying the annual percentage adjustment of the Medicare Economic Index (MEI) to the previous year's conversion factor for each service category identified in Rule 26,B,2,e,i. For purposes of this rule, the MEI means the input price index used by CMS to measure changes in the costs of providing physician services paid under the RBRVS.
3. Services subject to the Schedule of Fees for Medical Services shall be reimbursed at the lower of the fee schedule amount or the provider's billed charge. The fee schedule amount for a particular service shall be determined by first multiplying the relative value unit for the CPT code applicable to the service provided by the dollar conversion factor for the service
category in which the code is located. The resulting amount may then be modified by instructions or ground rules for the service category in which the code is located to arrive at the final fee schedule amount. Medical or surgical services not covered under the schedule shall be paid in full unless the payor has evidence that the provider's charge exceeds the regular charge for such service by Nebraska providers.
4. Coding for services subject to the Schedule of Fees for Medical Services shall be in accordance with the CPT manual published by the American Medical Association, and in accordance with the National Correct Coding Initiative (NCCI) established by CMS. A provider shall not fragment or unbundle charges imposed for a service except as consistent with the CPT manual and the NCCI. Coding by a provider may be changed by a workers' compensation insurer, risk management pool, or self-insured employer, or any adjustor, third-party administrator, or other agent acting on behalf of any such workers' compensation insurer, risk management pool, or selfinsured employer, only as consistent with the CPT manual and the NCCI and following consultation with the provider.

5. The Schedule of Fees for Medical Services shall not apply to costs and expenses incurred by or on behalf of any party for the purpose of proving or disproving a contested claim, except that X-rays, laboratory services, and other diagnostic tests provided in connection with a medical-legal evaluation shall be subject to the schedule.

C. The Diagnostic Related Group inpatient hospital fee schedule established in section 48-120.04 shall include the following Medicare Diagnostic Related Groups, effective January 1, 2018:
3 90 200 392 475 517 579 885 948
23 92 206 439 477 518 580 901 949
25 93 207 441 480 519 581 902 950
26 94 208 442 481 520 593 904 951
27 101 219 443 482 536 603 906 955
28 103 220 454 483 549 605 907 956
29 115 253 455 489 551 621 908 957
30 131 264 456 492 552 623 909 958
40 155 271 459 493 556 638 914 959
41 157 298 460 494 558 690 918 963
57 166 299 463 496 559 698 919 964
65 167 300 464 501 560 815 921 965
70 168 301 465 502 561 824 922 981
82 175 305 467 504 563 853 923 982
83 176 329 468 505 564 854 927 983
84 177 330 469 511 565 856 928 987
85 184 354 470 512 566 857 929
86 185 355 471 513 571 862 934
87 189 378 472 514 572 871 935
89 194 391 473 516 578 872 941

D. For inpatient hospital discharges prior to October 1, 2015, a claim for inpatient trauma services shall mean a claim which has at least one of the following ICD- 9-CM diagnosis codes in UB-04 Form Locator 67: Injury codes in the range of 800-959.9, 994.1, 994.7, or 994.8; and either: 1. The patient was admitted to the hospital from the emergency department (UB-04 Form Locator 14 with Priority (Type) of Visit as: I-Emergency, or 5-Trauma), or 2. The patient was transferred out of the hospital (UB-04 Form Locator 17
with Patient Discharge Status 02-Discharged/transferred to a Short Term General Hospital for Inpatient Care), or
3. The patient was admitted directly to the hospital, bypassing the emergency department (UB-04 Form Locator 14 with Priority (Type) of Visit as: 1- Emergency, or 5-Trauma), or
4. The patient died in the emergency department (UB-04 Form Locator 17 with Patient Discharge Status 20-Expired), or
5. The patient was dead on arrival in the emergency department (UB-04 Form Locator 17 with Patient Discharge Status 20-Expired).
E. For inpatient hospital discharges on or after October 1, 2015, a claim for inpatient trauma services shall mean a claim which has at least one of the following ICD-10-CM diagnosis codes in UB-04 Form Locator 67: Injury codes in the range ofM80, M84, S00-S99, T07-T34, T51-T79; and either:
1. The patient was admitted to the hospital from the emergency department (UB-04 Form Locator 14 with Priority (Type) of Visit as: I-Emergency, or 5-Trauma), or
2. The patient was transferred out of the hospital (UB-04 Form Locator 17 with Patient Discharge Status 02-Discharged/transferred to a Short Term General Hospital for Inpatient Care), or
3. The patient was admitted directly to the hospital, bypassing the emergency department (UB-04 Form Locator 14 with Priority (Type) of Visit as: 1- Emergency, or 5-Trauma), or
4. The patient died in the emergency department (UB-04 Form Locator 17 with Patient Discharge Status 20-Expired), or
5. The patient was dead on arrival in the emergency department (UB-04 Form Locator 17 with Patient Discharge Status 20-Expired). Sections 48-120, 48-120.04, RS. Supp., 2016.
Effective date: December 13, 2017.



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