Virginia Workers' Compensation Commission

Medical Fee Services Newsletter

Q2 2024

Regulatory Focus - 65.2-605.D

The Virginia Workers’ Compensation Commission shall review Virginia fee schedules during the year that follows the ​transition date and biennially thereafter and, if necessary, adjust the Virginia fee schedules in order to address (i) ​inflation or deflation as reflected in the medical care component of the Consumer Price Index for All Urban ​Consumers (CPI-U) for the South as published by the Bureau of Labor Statistics of the U.S. Department of Labor; (ii) ​access to fee scheduled medical services; (iii) errors in calculations made in preparing the Virginia fee schedules; and ​(iv) incentives for providers.

The Commission shall not adjust a Virginia fee schedule in a manner that reduces fees on an existing schedule unless ​such a reduction is based on deflation or a finding by the Commission that advances in technology or errors in ​calculations made in preparing the Virginia fee schedules justify a reduction in fees.

Greetings from the Manager

For this edition, we want to begin by thanking the many stakeholders that took time out to attend the MFS Calculator ​training that was held on February 15, 2024. There were approximately 150 users that entered our Virtual training ​space. As many of you began to utilize this new resource, the team received follow-up questions and comments, and ​several are included in this edition along with the helpful links to the calculator tutorial and reference manual.

It seems as though we just welcomed in the new year and the effective date of the 2024 schedules. In upcoming ​events, soon we will begin the early stages for the next biennial review. The Commission website will be the first ​source to keep stakeholders up to date.

Lastly, the Commission wants to hear from you! As we begin to plan for the next MFS Symposium, please complete ​the survey questions and let us know regarding topics or speakers.

Best regards,

Dr. Drema Thompson

Medical Fee Services Manager

The MFS Calculator | Your Concerns/Our Answers

Q. My bill includes multiple modifiers, do I have to list them in any order?

A. The MFS Calculator will determine the order of applicable modifiers to calculate the adjusted max fee.

Q. Can the calculator calculate fees for the Type One Teaching Hospitals? If so, where do I enter that?

A. Type One Teaching hospitals are defined as a state-owned teaching hospital effective as of January 1, 1996. These

hospitals are only located in regions 2 and 3 and have maximum fee values assigned for all applicable billing codes.

Therefore, if your ​region of service is in any region other than 2, or 3, or the billing code is not applicable, and you

select a Type One ​teaching hospital option, the result will be not applicable (N/A).

Q. Can you explain why I received this message when using the Medical Fee Schedule Calculator?

Billing code not found.

Enter Secondary CPT or HCPCS

A. The MFS Calculator will only return an Adjusted Max Fee value for codes that are currently listed in the schedules. ​

Please contact the Medical Fee Services department for further assistance.

The absence of any code from the medical fee schedule does not mean that the medical services corresponding to

that code are services outside of the scope of coverage provided by the Virginia Workers’ Compensation Act. Please

contact the Medical Fee Services Department for additional information.

The Medical Fee Schedule (MFS) Calculator was deployed in December 2023, to provide stakeholders with a user-friendly access point to search and retrieve maximum fee values from the medical fee schedule and lessen manual calculations. This Commission tool returns the fee scheduled maximum assigned amount and incorporates applicable Ground Rules adjustments to return the Adjusted Maximum Fee.

NEW: MFS Calculator Tutorial

MFS Calculator Best Practices

The MFS Calculator is a tool intended to assist in the application and understanding of the Medical Fee ​Schedules and ​the Ground Rules document, located here.

For a complete listing of helpful hints and best practices, please visit the MFS Calculator Reference Manual. Here are ​a few best practices:

1. What do I enter when the calculator indicates a secondary code is required and I do not have an additional code to enter?

If the calculator prompts the entry of a Secondary Code for services other than implantable devices or injectable drugs, and a valid CPT/HCPCS is not listed re-enter the Billing Code to obtain the maximum fee.

If you know that you are entering a valid code and continue to receive a message that the billing code is not found; the medical services as described by the billing code have not been assigned a maximum fee. Either the code is too new or there was not sufficient experience in the medical services data to determine the maximum assigned amount for the MFS year in your search. Please contact the Medical Fee Services Department for further assistance as indicated in the Ways to Contact MFS Section listed below.

2. What if the billing code is not found after re-entering the code in the Secondary code field as prompted?

Once the zip code and JCN fields are entered and the “Create Bill” button is depressed, the calculator will not allow ​further edits. Depress the “Clear Bill” button to start over.

3. Lesser than Logic (LOL)

The fee schedule maximum amount is the lesser of billed charges and the maximum fee shown in the applicable fee ​schedule. The calculation will automatically adjust to the LOL when returning the adjusted maximum fee.

Did You Know?

Reimbursement of Non-Physician Practitioners (NPPs) include professionals such as a nurse practitioner, physician assistant, clinical nurse specialist, clinical psychologist, clinical social worker, physical therapist, occupational therapist, or speech therapist. NPPs shall be reimbursed according to the rules outlined in the Maximum Fee Reimbursement section of the Ground Rules document. No adjustment shall be applied to the applicable maximum fee appearing on the MFS, regardless of whether the NPP bills for the service under the physician’s NPI or their own for non-surgical procedures, beyond those outlined in the CPT/HCPCS Modifiers section in the Ground Rules document.

How to reimburse for out of state providers: any health care provider located outside of the Commonwealth who provides health care services under the Virginia Workers’ Compensation Act to a claimant shall be reimbursed based on the principal place of business of the employer if located in the Commonwealth or, if no such location exists, then the location where the Commission hearing regarding the dispute is conducted.

The Medical Fee Schedule does not apply to:

• Health care services subject to a written contract between a health care provider and an employer or insurance carrier.
• Health care services for which voluntary payments in excess of the reimbursement levels of the MFS are made by a self-insured employer or an insurance carrier.
• Physician dispensed, retail or mail order prescription drugs.
• Air ambulances.
• Durable medical equipment dispensed through a retail DME provider.
• Facility services associated with a traumatic injury.
• Professional services associated with a traumatic injury.
• Facility services associated with a serious burn; and
• Professional services associated with a serious burn.
  

Helpful Links

MFS Training Opportunities

Topics below are available in-person or virtually.

Understanding the Nuts and Bolts of the Medical Fee Schedules

• Provides a comprehensive review of the MFS Regulations
  
• Introduces the roles and responsibilities of the Commission and Regulatory Advisory Panel
  
• Explores key MFS schedule data elements
  
• Explains the role of the Ground Rules
  

Impacts and Influences of the Medical Fee Schedules

• Clarifies implications for Providers and Payers
  
• Illustrates the MFS review and maintenance of schedules
  

Medical Fee Schedule Dispute Resolution

• Reviews forms and notices
  
• Gives examples of required documentation
  
• Provides examples of key applicable coding conventions
  
• Discusses MFS exclusions and dispute resolution
  

Breaking down the Administrative Determination

• Reviews the importance of supporting medical records
  
• Explores the administrative decision components
  
• Discusses the process to appeal the decision
  

Medical Provider Inquiry Forms

• Reviews the importance of supporting medical records
  
• Explores the administrative decision components
  
• Discusses the process to appeal the decision
  

MFS Calculator Training

• Review the statutory governance and how it influences Commission Medical Fee Services activities such as the development of the calculator.
• Identify key workers’ compensation system experiences and how they intersect with the Commission’s Medical Fee Services goals.
• Review key considerations in navigating the calculator in order to utilize the tool effectively.
• Review the outcomes for medical service codes and applicable Ground Rule adjustments for maximum fee values.
  

Ways to Contact MFS

Contact the Medical Fee Services Department toll-free at 877-664-2566.

Below are recommendations for the best ways to contact MFS depending on your need.