Under A.R.S. § 23-908(B), the Commission is required to establish a schedule of fees to be charged by physicians and physical therapists or occupational therapists attending injured employees. The Commission is also required to establish a schedule of fees for prescription medicines required to treat an injured employee.
For purposes of the Fee Schedule, the term "physician" includes chiropractors and naturopaths.
Fees for certain products, supplies, and services are not included in the Fee Schedule. This includes fees for ambulance services, durable medical equipment, prosthetics, orthotics, and supplies when used outside a physician's office. If a product, supply, or services are not included in the Fee Schedule, there will not be a code for those items in the Fee Schedule (e.g., codes from Medicare's Healthcare Common Procedure Coding System, HCPCS).
6. What is the appropriate fee for products, supplies, or services not covered under the Fee Schedule? Is it "usual, customary, and reasonable (UCR)"?
If a product, supply, or service is not covered under the Arizona Fee Schedule, then the Commission has no jurisdiction to set a fee or resolve a fee dispute related to the service. Additionally, while the obligation of a payer under the Arizona Workers' Compensation Act is to provide medical benefits that are reasonably required, neither the Arizona Workers' Compensation Act, A.R.S. § 23-901 et seq., nor the Arizona Physicians' Fee Schedule make reference to the phrase "usual, customary and reasonable." You may wish to consult an attorney for further assistance regarding this issue.
7. May a provider bill for services using a code that has not been adopted by the Commission?
A provider is not precluded from billing for a service for which there is no corresponding code in the current Fee Schedule. But, for such a code, since there is no reimbursement value set forth in the Fee Schedule, reimbursement for the service performed is subject to negotiation between the parties. See Section (B) (4) of the Fee Schedule Introduction. As an alternate to billing under a code that has not yet been adopted, some providers will use an otherwise applicable code or an "unlisted service or procedure" code in the current fee schedule.
8. May a provider covered by the Fee Schedule negotiate a fee that is different than the Fee Schedule?
Yes. Nothing in the Fee Schedule precludes an entity covered under the Fee Schedule from entering into a separate contract that addresses fees for service.
9. Does the Fee Schedule apply to services provided by out-of-state providers?
The Fee Schedule applies to fees charged by covered entities attending employees that are entitled to receive workers' compensation benefits under the Arizona Workers' Compensation Act.
10. Does the Fee Schedule apply to fees charged by chiropractors and naturopaths?
11. Does the Fee Schedule apply to fees charged by nurse practitioners, physician assistants, or certified nurse anesthetists?
Yes. Certified Registered Nurse Anesthetists are reimbursed at 85% of the Fee Schedule. Physician Assistants and Nurse Practitioners are reimbursed at 85% of the Fee Schedule except if services are provided “incident to” a physician’s professional services. In that instance, reimbursement is required to be made at 100% of the Fee Schedule. See Section C of the Introduction, Reimbursement of Mid-Level Providers for additional information.
12. Does the Fee Schedule apply to fees charged by Physical Therapy Assistants?
The Fee Schedule applies to Physical Therapist and not Physical Therapy Assistants. Please see questions 5 and 6.
13. Does the Fee Schedule apply to fees charged by hospitals or outpatient surgery facilities?
No. See also answers to questions 5 and 6.
14. Does the Fee Schedule apply to charges for materials and supplies used in the physician's office?
A physician is not entitled to be reimbursed for supplies and materials normally necessary to perform the service. A physician may charge for other supplies and materials using code 99070. A physician may use an applicable HCPCS code in lieu of code 99070 if the HCPCS code more accurately describes the materials and supplies provided by the physician. Examples of those items that are and are not reimbursable are listed below. Documentation showing actual costs associated with providing supplies and materials plus fifteen percent (15%) to cover overhead costs will be adequate justification for payment. This provision does not apply to retail operations involving drugs or supplies. Administration of drugs to patients in a clinical setting is covered under code 99070. Prescription drugs provided to patients as a part of the overall treatment regimen but outside of the clinical setting are not included under this code.
Examples of supplies that are not separately reimbursable:
- Eye patches, injections, or debridement trays
- Applied eye wash or eye drops
- Creams (massage)
- Sterile water
- Band-Aids® and dressings for simple wound occlusion
- Head sheets
- Aspiration trays
- Tape for dressing
Examples of material and supplies that are generally reimbursable include:
- Cast and strapping materials
- Sterile trays for laceration repair and more complex surgeries
- Applied dressings beyond simple wound occlusion
- Taping supplies for sprains
- Iontophoresis electrodes
- Reusable patient-specific electrodes
- Dispensed items, including canes, braces, slings, ACE® wraps, TENS electrodes, crutches, splints, back support, dressings, hot or cold packs.
15. Does the Fee Schedule apply to charges for ambulance services, durable medical equipment, prosthetics, orthotic supplies, or surgical implants?
No. See also answers to questions 5 and 6.
16. Does the Fee Schedule apply to fees charged for independent medical examinations?
17. Does the Pharmaceutical Fee Schedule permit a Payer to choose the publication source for determining Average Wholesale Price?
No. Average wholesale price shall be determined from pricing published in a nationally recognized pharmaceutical publication designed by the Commission. The Commission has selected Medi-Span.
18. What publication is required to be used for purposes of determining Average Wholesale Price?
Average wholesale price shall be determined on the date a drug is dispensed from pricing published in the most recent issue, as updated in the most recent update, of a nationally recognized pharmaceutical publication designated by the Commission. The Commission has selected Medi-Span.
An entity responsible for payment of prescription drugs may select the following as an alternative to the foregoing if the selection is made no later than October 1st of each year. This selection shall be communicated in writing to the Commission and remain in effect until the following October 1st: AWP shall be determined on the date a drug is dispensed from pricing published in the most recent issue, as updated quarterly, of the publication designed by the Commission. For purposes of this paragraph, quarterly means the first day of the month on January, April, July, and October. Click here
19. Does the Pharmaceutical Fee Schedule apply to repackaged medicines dispensed by a physician?
The Fee Schedule applies to the dispensing of prescription drugs, regardless of whether the drug is dispensed by a retail establishment or by a physician. The reimbursement rate is based on a discount from AWP plus a dispensing fee. The dispensing fee does not apply to an OTC medication that is not dispensed pursuant to a prescription order.
20. What is the Average Wholesale Price for repackaged drugs?
For purposes of the Fee Schedule, "average wholesale price" is the average wholesale price (AWP) established by a wholesaler who sells that brand name or generic drug to a pharmacy. For a repackaged or compounded drug, this would be the AWP of the underlying drug product used in the repackaging or compounding. If information pertaining to the original labeler of the underlying drug product is not provided or unknown, then discretion is vested in the payer to select the AWP to use (as published in Medi-Span) when making payment for the repackaged or compounded drug. Stated another way, the NDC number upon which reimbursement is based is not the NDC of the repackager. Instead, reimbursement is based upon the underlying drug product from the original labeler.
21. I am a physician and I have been subpoenaed to provide telephonic court testimony. How do I bill for my services?
If the physician wishes to submit an invoice, the invoice must be sent to the Industrial Commission’s Administrative Law Judge Division. The address of this Division is located on the subpoena that the physician received. The physician is entitled to bill under code 99099 (expert testimony) at a rate of $110 per hour. The invoice must include the name of the injured worker and the date that the physician provided testimony.
22. What are the new Arizona Treatment Guidelines and do they affect the Fee Schedule?
The treatment guidelines are a set of twelve rules published in Title 20, Chapter 5 of Arizona’s Administrative Code (see A.A.C.R20-5-1301through R20-5-1312). Please click here to view the Treatment Guideline Rules.
The Treatment Guidelines became effective October 1, 2016 and apply to the management of chronic pain and the use of opioids for all stages of pain management.
The Arizona Physicians and Pharmaceutical Fee Schedule is not affected by the Treatment Guidelines. However, because of the Treatment Guidelines, two new codes have been added to the 2016/2017 Arizona Physician’s and Pharmaceutical Fee Schedule. These codes are to reimburse medical providers for time spent in telephone consultations with Peer Reviewers.
AZ-099-001 = Peer to Peer interprofessional telephone consultations between treating physician or medical provider and Peer Reviewer ; 5-10 minutes or medical consultative discussion and review. $75
AZ-99-002 = Peer to Peer interprofessional telephone consultations between treating physician or medical provider and Peer Reviewer; 11-30 minutes of medical consultative discussion and review. $100
23. The Treatment Guidelines discuss the use of the Official Disability Guidelines (ODG) and Appendix A, the ODG Drug Formulary. Do we need to access to the ODG to access the Arizona Physician’s and Pharmaceutical Fee Schedule?
No. The Industrial Commission of Arizona has adopted the Work Loss Data Institute’s Official Disability Guidelines (ODG) – Treatment in Workers Compensation as the standard reference for evidence based medicine for the management of chronic pain and the use of opioids for all stages of pain management within the context of Arizona’s workers compensation system. This is a separate online publication which has to be purchased through Work loss Data Institute. It is not necessary to have access to ODG in order to access the Arizona Physicians and Pharmaceutical Fee Schedule
24. Where can explanations regarding add-on Codes and codes exempt from modifier -51 be found?
Previously the AMA Professional Edition CPT® (current procedural terminology) used the symbols * and ** throughout the CPT® to indicate codes which were add-on codes or codes that are exempt from Modifier -51. These codes are now indicated on Appendix D Summary of CPT Add-on codes 2016 and Appendix E Summary of CPT codes EXEMPT from Modifier -51 for 2016. Appendix D and Appendix E are attached to the 2016/2017 Arizona Physician’s and Pharmaceutical Fee Schedule Tables. Please click here.