Hawaii Administrative Rules › Title 12 - DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS › Chapter 15 - WORKERS COMPENSATION MEDICAL FEE SCHEDULE & EXHIBIT A › Subchapter 3 - TREATMENT › Section 12-15-51 - Surgery

Current through June, 2024
(a) When elective surgery is contemplated,
				the attending physician shall obtain permission from the employer at least
				seven calendar days prior to the date of the proposed surgery. Written
				notification shall include procedure code, medical documentation justifying the
				need for surgery, the estimated date of surgery, and the hospital where the
				surgery is to be performed. The notification shall permit the employer to
				determine whether the injured employee should be examined by a physician of the
				employer's choice as provided under section
				386-79,
				HRS. Any physician who performs surgery in a manner which denies the rights of
				the employer as provided under section
				386-79,
				HRS, shall forfeit the physician's right to fees. When the surgical procedure
				has a "BR" (by report) fee, the estimated fee shall be submitted with the
				request. The physician's request shall also specify the cost and need for a
				co-surgeon or assistant and other additional surgical procedures, if
				any.
(b) Whenever a request for
				elective surgery is received, the employer shall respond within seven calendar
				days after postmark of such request, giving authorization or stating in writing
				the reason for refusal, to the attending physician, the injured employee, and
				the director. The employer's denial of elective surgery shall be supported by
				health care recommendations and shall explicitly state that failure to request
				a review by the director of the employer's denial within fourteen calendar days
				after postmark of the employer's denial shall be construed as acceptance of the
				employer's denial. If a request for a surgical procedure has been denied, the
				attending physician may not resubmit the same request for the same surgical
				procedure for forty-five calendar days after postmark of the employer's denial.
				Failure by the employer to respond within seven calendar days shall constitute
				approval of the request.
(c) The
				attending physician or the injured employee may request in writing that the
				director review the employer's denial of the request for elective surgery. The
				request for review shall be filed with the director, copying the employer,
				within fourteen calendar days after postmark of the employer's denial. Failure
				to file a request for review of the employer's denial to the director within
				fourteen calendar days after postmark of the employer's denial shall be deemed
				acceptance of the employer's denial, and the attending physician may not
				resubmit the same request for the same surgical procedure for forty-five
				calendar days after postmark of the employer's denial. The director shall hold
				a hearing on the request for review, and issue a decision approving or denying
				the request for elective surgery based on the evidence presented (inclusive of
				records on file). The decision shall be final unless appealed pursuant to
				section
				386-87,
				HRS. The appeal shall not stay the director's decision.
(d) Surgery which must be performed
				immediately or within fourteen calendar days because the condition is
				life-threatening or could cause serious harm is not considered elective
				surgery. The attending physician shall notify the director and the employer as
				soon as possible when emergency surgery is required.
(e) When a surgical fee is chargeable, no
				office or hospital visit charge shall be allowed for the day on which this
				surgical fee is earned, except if surgery is performed on the same day as the
				physician's first examination.
(f)
				Listed fees for all surgical procedures include the surgery and the follow-up
				care for the period indicated in days in the column headed "Follow-up Days" in
				the medical fee schedule. Necessary follow-up care beyond this listed period is
				to be added on a fee-for-service basis. Where the follow-up period is listed as
				zero, the listed fee is for the surgical procedure only, and all post-operative
				care is to be added on a fee-for-service basis.
(g) When additional surgical procedures are
				carried out within the listed period of follow-up care for a previous surgery,
				the follow-up periods shall continue concurrently to their normal
				terminations.
(h) Certain of the
				listed procedures in the medical fee schedule as provided in section 12-15-90
				are commonly carried out as an integral part of a total service and, as such,
				do not warrant a separate charge. When such a procedure is carried out as a
				separate procedure, not immediately related to other services, the indicated
				fee is applicable.
(i) When
				significant time or complexity to patient care results from multiple or
				bilateral surgical procedures performed at the same operative session, the
				total fee shall be the fee for the major procedure plus fifty per cent of the
				fee of the lesser procedures unless otherwise specified in this chapter. When
				an incidental procedure (e.g., incidental appendectomy, lysis of adhesions,
				excision of previous scar) is performed through the same incision, the fee
				shall be that of the major procedure only.
(j) One attending physician shall be in
				charge of the care of the injured employee. However, if the nature of the
				injury requires the concurrent services of two or more specialists for
				treatment, then each physician shall be entitled to the listed fee for services
				rendered.
(k) Lacerations
				ordinarily require no aftercare except removal of sutures. The removal is
				considered a routine part of an office or hospital visit.
(l) For those fees not covered by Medicare,
				bills for services for injured employees who have had major surgery or
				treatment for major fractures and are later treated by another physician for
				follow-up care shall be limited to the fee schedule during the entire follow-up
				period as follows:
(1) The operating surgeon
				shall submit a fee, reducing it accordingly if aftercare is not
				rendered.
(2) The physician
				providing follow-up care shall submit the fee for the aftercare.
(3) It shall be the responsibility of the
				operating surgeon to advise the director or employer of the apportionment of
				the respective fees.