04 NCAC 10J .0102           Fees for PROFESSIONAL SERVICES

(a)  The Commission's Medical Fee Schedule sets the maximum allowed amounts for professional medical services provided pursuant to Chapter 97 of the General Statutes.  The Medical Fee Schedule utilizes 1995 through the present, Current Procedural Terminology ("CPT") codes adopted by the American Medical Association and Healthcare Common Procedure Coding Systems ("HCPCS") codes.  A listing of the maximum allowable amount for each code is available in the Medical Fee Schedule on the Commission's website at http://www.ic.nc.gov/ncic/pages/feesched.asp and in hardcopy at the offices of the Commission as set forth in Rule 04 NCAC 10A .0101.

(b)  The following methodology provides the basis for the Commission's Medical Fee Schedule:

(1)           CPT codes for General Medicine are based on 1995 North Carolina Medicare values multiplied by 1.58, except for CPT codes 99201-99205 and 99211-99215, which are based on 1995 Medicare values multiplied by 2.05;

(2)           CPT codes for Physical Medicine are based on 1995 North Carolina Medicare values multiplied by 1.36;

(3)           CPT codes for Radiology are based on 1995 North Carolina Medicare values multiplied by 1.96; and

(4)           CPT codes for Surgery are based on 1995 North Carolina Medicare values multiplied by 2.06.

 

History Note:        Authority G.S. 97-25; 97-26; 97-80(a);

Eff. April 1, 2015.

 

04 NCAC 10J .0102           FEES FOR PROFESSIONAL SERVICES

(a)  Except as otherwise provided in this Rule, maximum allowable amounts payable to health care providers for professional services shall be based on the current year's Medicare Part B Fee Schedule for North Carolina ("the Medicare base amount"), as published by the Centers for Medicare & Medicaid Services ("CMS") or its administrative contractor, including subsequent versions and editions.  The Medicare Part B Fee Schedule for North Carolina can be found at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html.

(b)  The schedule of maximum reimbursement rates for professional services is as follows:

(1)           evaluation & management services are 140 percent of the Medicare base amount;

(2)           physical medicine services are 140 percent of the Medicare base amount;

(3)           emergency medicine services are 169 percent of the Medicare base amount;

(4)           neurology services are 153 percent of the Medicare base amount;

(5)           pain management services are 163 percent of the Medicare base amount;

(6)           radiology services are 195 percent of the Medicare base amount;

(7)           major surgery services are 195 percent of the Medicare base amount; and

(8)           all other professional services are 150 percent of the Medicare base amount.

(c)  The schedule of maximum reimbursement rates for anesthesia services is as follows:

(1)           when provided by an anesthesiologist, the allowable amount is three dollars and eighty-eight cents ($3.88) per minute up to and including 60 minutes, and two dollars and five cents ($2.05) per minute beyond 60 minutes; and

(2)           when provided by a certified registered nurse anesthetist, the allowable amount is two dollars and fifty-five cents ($2.55) per minute up to and including 60 minutes, and one dollar and fifty-five cents ($1.55) per minute beyond 60 minutes.

(d)  The maximum allowable amount for an assistant at surgery is 20 percent of the amount payable for the surgical procedure.

(e)  Using the Medicare base amounts and maximum reimbursement rates in Paragraphs (a) through (d) of this Rule,  the Commission shall publish annually an official Professional Fee Schedule Table listing allowable amounts for individual professional services in accordance with this fee schedule.  The allowable amounts contained in the Professional Fee Schedule Table shall take effect January 1 of each year. The Professional Fee Schedule Table is available as set forth in Rule .0101(b) of this Section and in hardcopy at the offices of the Commission as set forth in Rule 04 NCAC 10A .0101.

(f)  Maximum allowable amounts for durable medical equipment and supplies ("DME") provided in the context of professional services are 100 percent of those rates established for North Carolina in the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies ("DMEPOS") Fee Schedule published by CMS.  The DMEPOS can be found at http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html. The Commission will publish annually on its website an official DME Fee Schedule Table listing allowable amounts for individual items and services in accordance with this fee schedule.  The allowable amounts contained in the DME Fee Schedule Table will take effect January 1 of each year. The DME Fee Schedule Table is available as set forth in Rule .0101(b) of this Section and in hardcopy at the offices of the Commission as set forth in Rule 04 NCAC 10A .0101.

(g)  Maximum allowable amounts for clinical laboratory services are 150 percent of those rates established for North Carolina in the Clinical Diagnostic Laboratory Fee Schedule published by CMS. The CMS Clinical Laboratory Fee Schedule can be found at http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/clinlab.html. The Commission will publish annually on its website an official Clinical Laboratory Fee Schedule Table listing allowable amounts for individual items and services in accordance with this fee schedule.  The allowable amounts contained in the Clinical Laboratory Fee Schedule Table will take effect January 1 of each year. The Clinical Laboratory Fee Schedule Table is available as set forth in Rule .0101(b) of this Section and in hardcopy at the offices of the Commission as set forth in Rule 04 NCAC 10A .0101.

(h)  The following licensed health care providers may provide professional services in workers' compensation cases subject to physician supervision and other scope of practice requirements and limitations under North Carolina law:

(1)           certified registered nurse anesthetists;

(2)           anesthesiologist assistants;

(3)           nurse practitioners;

(4)           physician assistants;

(5)           certified nurse midwives; and

(6)           clinical nurse specialists.

Services rendered by these providers are subject to the schedule of maximum fees for professional services as provided in this Rule.

 

History Note:        Authority G.S. 97-25; 97-26; 97-80(a); S.L. 2013-410;

Eff. April 1, 2015;

Amended Eff. July 1, 2015.