02.
Proceedings to Secure Benefits.
a. Initial Determination by CVCP Division. After sufficient information has been gathered, the CVCP Division may make an initial determination granting, partially granting, or denying benefits. An initial determination of the CVCP Division shall be final and conclusive as to all matters adjudicated in the determination
b. Request for Reconsideration. Within twenty (20) days from the date that the initial determination is issued, the claimant may file a request with the CVCP Division that the division reconsider its decision, or the CVCP Division may reconsider the matter on its own motion. The decision of the CVCP Division on reconsideration shall be final and conclusive as to all matters adjudicated in the decision.
03.
Allowable Payments for Medical Services. The Commission shall pay providers the allowable payment for medical services under these rules adopted in accordance with Section
72-1026, Idaho Code.
a. Adoption of Standard. The Commission hereby adopts the Resource-Based Relative Value Scale (RBRVS), published by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services, as amended, as the standard to be used for determining the allowable payment under the Crime Victims Compensation Act for medical services provided by providers other than hospitals and ASCs. The standard for determining the allowable payment for hospitals and ASCs shall be:
i. For large hospitals: Eighty-five percent (85%) of the reasonable inpatient charge.
ii. For small hospitals: Ninety percent (90%) of the reasonable inpatient charge.
iii. For ambulatory surgery centers (ASCs) and hospital outpatient charges: Eighty percent (80%) of the reasonable charge.
iv. Surgically implanted hardware shall be reimbursed at the rate of actual cost plus fifty percent (50%).
v. Paragraph 011.03.e. of this rule, does not apply to hospitals or ASCs. The Commission shal l determine the allowable payment for hospital and ASC services based on all relevant evidence.
b. Conversion Factors. The following conversion factors shall be applied to the fully-implemented facility or non-facility Relative Value Unit (RVU) as determined by place of service found in the latest RBRVS, as amended, that was published before December 31 of the previous calendar year for a medical service identified by a code assigned to that service in the latest edition of the Physicians' Current Procedural Terminology (CPT), published by the American Medical Association, as amended:
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MEDICAL FEE SCHEDULE
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DESCRIPTION
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CODE RANGE(S)
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CONVERSION FACTOR
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|
Anesthesia
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00000 - 09999
|
|
$60.05
|
|
Surgery -Group One
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22000 - 22999
23000 - 24999
25000 - 27299
27300 - 27999
29800 - 29999
61000 - 61999
62000 - 62259
63000 - 63999
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Spine
Shoulder, Upper Arm, & Elbow
Forearm, Wrist, Hand, Pelvis & Hip
Leg, Knee, & Ankle
Endoscopy & Arthroscopy
Skull, Meninges & Brain
Repair, Neuroendoscopy & Shunts
Spine & Spinal Cord
|
$144.48
|
|
Surgery -Group Two
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28000 - 28999
64550 - 64999
|
Foot & Toes
Nerves & Nervous System
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$129.00
|
|
Surgery -Group Three
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13000 - 19999
20650 - 21999
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Integumentary System
Musculoskeletal System
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$113.52
|
|
Surgery -Group Four
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20000 - 20615
30000 - 39999
40000 - 49999
50000 - 59999
60000 - 60999
62260 - 62999
64000 - 64549
65000 - 69999
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Musculoskeletal System
Respiratory & Cardiovascular
Digestive System
Urinary System
Endocrine System
Spine & Spinal Cord
Nerves & Nervous System
Eye & Ear
|
$87.72
|
|
Surgery -Group Five
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10000 - 12999
29000 - 29799
|
Integumentary System
Casts & Strapping
|
$69.14
|
|
Radiology
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70000 - 79999
|
Radiology
|
$87.72
|
|
Pathology & Laboratory;
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80000 - 89999
|
Pathology & Laboratory
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To Be Determined
|
|
Medicine -Group One
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90000 - 90749
94000 - 94999
97000 - 97799
97800 - 98999
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Immunization, Injections, & Infusions
Pulmonary / Pulse Oximetry
Physical Medicine & Rehabilitation
Acupuncture, Osteopathy, & Chiropractic
|
$46.44
|
|
Medicine -Group Two
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90750 - 92999
96040 - 96999
99000 - 99607
|
Psychiatry & Medicine
Assessments & Special Procedures
E / M & Miscellaneous Services
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$66.56
|
|
Medicine -Group Three
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93000 - 93999
95000 - 96020
|
Cardiography, Catheterization, & Vascular Studies
Allergy / Neuromuscular Procedures
|
$72.24
|
c. The Conversion Factor for the Anesthesiology CPT Codes shall be multiplied by the Anesthesi a Base Units assigned to that CPT Code by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services as of December 31 of the previous calendar year, plus the allowable time units reported for the procedure. Time units are computed by dividing reported time by fifteen (15) minutes. Time units will not be used for CPT Code 01996.
d. Adjustment of Conversion Factors. The conversion factors set out in this rule may be adjusted each fiscal year (FY), starting with FY 2012, as determined by the Commission.
e. Services Without a CPT Code, RVU or Conversion Factor. The allowable payment for medical services that do not have a current CPT code, a currently assigned RVU, or a conversion factor will be the reasonable charge for that service, based upon the usual and customary charge and other relevant evidence, as determined by the Commission. Where a service with a CPT Code, RVU, and conversion factor is, nonetheless, claimed to be exceptional or unusual, the Commission may, notwithstanding the conversion factor for that service set out in Subsection 011.07.b. of this rule, determine the allowable payment for that service, based on all relevant evidence.
f. Coding. The Commission will generally follow the coding guidelines published by the Centers for Medicare and Medicaid Services and by the American Medical Association, including the use of modifiers. The procedure with the largest RVU will be the primary procedure and will be listed first on the claim form. Modifiers will be reimbursed as follows:
i. Modifier 50: Additional fifty percent (50%) for bilateral procedure.
ii. Modifier 51: Fifty percent (50%) of secondary procedure. This modifier will be applied to each medical or surgical procedure rendered during the same session as the primary procedure.
iii. Modifier 80: Twenty-five percent (25%) of coded procedure.
iv. Modifier 81: Fifteen percent (15%) of coded procedure. This modifier applies to MD and non-MD assistants.
