Code of Vermont Rules › Agency 24 - DEPARTMENT OF LABOR › Sub-Agency 010 - ADMINISTRATIVE DIVISION › Chapter 006 - WORKERS' COMPENSATION MEDICAL FEE SCHEDULE - RULE 40.000 › Section 24 010 006 - WORKERS' COMPENSATION MEDICAL FEE SCHEDULE - RULE 40.000

Current through June, 2024
Section 40.000 Workers' Compensation Medical
			 Fee Schedule
The five-digit numeric codes and descriptions included in Rule
				40. 000, Medical Fee Schedule, are obtained from the Physicians' Current
				Procedural Terminology, Copyright 2005 and any updates thereto, by the American
				Medical Association (CPT). Appendix I of Rule
				40.000 shall be updated on
				April 1 of each consecutive year to reflect any additions, deletions and
				modifications of the CPT Codes contained in any update to the Physicians'
				Current Procedural Terminology, Copyright 2005. CPT is a listing of descriptive
				terms and numeric identifying codes and modifiers for reporting medical
				services and procedures performed by physicians.
This publication includes only CPT numeric identifying codes
				and modifiers for reporting medical services and procedures that were selected
				by the Vermont Department of Labor. Any use of CPT outside the fee schedule
				should refer to the Physicians' Current Procedural Terminology, copyright 2005
				American Medical Association and any update thereto. These CPT publications
				contain the complete and most current listing of CPT descriptive terms and
				numeric identifying codes and modifiers for reporting medical services and
				procedures.
No fee schedules, basic unit values, relative value guides,
				conversion factors or scales are included in any part of the Physicians'
				Current Procedural Terminology, copyright 2005 American Medical Association and
				any update thereto. All rights reserved.
Section 40.010 General Provisions
Section 40.011 Authority and Purpose
This rule is promulgated by the Vermont Department of Labor
				under the authority of
				21
				V.S.A. §
											640(d). It
				establishes that the liability of an employer to pay for medical, surgical,
				hospital and nursing services provided to an injured employee shall not exceed
				the maximum fee for a particular service as provided for in this rule.
Section 40.012 Definitions
(A) "Charge" shall mean the amount billed by
			 the health care provider or health care facility to all payers for the same
			 service, whether under workers' compensation or not. Hospitals shall provide an
			 electronic copy of their charge master to the department within 45 days of the
			 effective date of this rule.
(B)
			 "CPT code" means a numeric code, included in the Current Procedure Terminology
			 manual, used to identify a specific medical service, article or supply. The
			 Current Procedure Terminology manual is published by and may be purchased from
			 the American Medical Association, Order Department: OP054194HA, P.O. Box 10950,
			 Chicago, Illinois 60610.
(C)
			 "Commissioner" means the Commissioner of the Vermont Department of
			 Labor.
(D) "Follow-up Days (FUD)"
			 means the maximum number of days of care following a surgical procedure that
			 are included in the procedure's maximum allowable payment but does not include
			 care for complications, exacerbations, recurrent, or other diseases or
			 injuries.
(E) "Health care
			 facility" shall mean the same as defined in
			 18 V.S.A. §
											9432(7).
(F) "Health care provider" shall mean the
			 same as defined in
			 18 V.S.A. §
											9432(8).
(G) "Hospital" shall mean the same as defined
			 in
			 18 V.S.A. §
											1902(a) and shall be
			 licensed in its state of domicile.
(H) "Incidental Surgery" means a surgery
			 which is performed on the same patient, on the same day, by the same doctor but
			 is not related to the diagnosis.
(I) "Maximum Allowable Payment" means the
			 maximum fee for a procedure listed in Appendix I, subject to the provisions of
			 section 40.020 of this rule, or the health care facility's or health care
			 provider's charge whichever is less. For those procedures having no code listed
			 in Appendix I of this fee schedule, payment shall not exceed 83% of the charge
			 for the service. This percentage shall be adjusted annually to consider any
			 increase or decrease in the total operating expense of all hospitals based on
			 hospital budget submissions to the Department of Banking, Insurance,
			 Securities, and Health Care Administration (BISHCA). The change shall be
			 calculated using the ratio of the new cost-to-charge ratio to the prior year
			 cost-to-charge ratio.
(J)
			 "Modifier" means a two-digit number that is added to a procedure code to
			 indicate that the service rendered differs in some material respect from the
			 service described in this rule or in the Current Procedure Terminology manual
			 in effect on the date the service was rendered.
(K) "Nursing home", "residential care home",
			 and "therapeutic community residence" shall mean the same as defined in
			 33 V.S.A. §
											7102 and shall be licensed in its state of
			 domicile.
(L) "Health Insurer",
			 means any health insurance company, nonprofit hospital and medical service
			 corporation and managed care organizations.
(M) "Employer", includes any body of persons,
			 corporate or unincorporated, public or private, and the legal representative of
			 a deceased employer, and includes the owner or lessee of premises or other
			 person who is virtually the proprietor or operator of the business there
			 carried on, but who, by reason there being an independent contractor or for any
			 other reason, is not the direct employer of the worker there employed. If the
			 employer is insured, "employer" includes the carrier so far as applicable. (
			 21 V.S.A. §
											601(3) and § 687
			 ).
(N) "Insurance Carrier",
			 includes any corporation from which an employer has obtained workers'
			 compensation or guaranty insurance in accordance with the provisions of
			 21 V.S.A. §
											601.
(O) "Medical Necessity", Workers'
			 compensation insurers are only responsible for paying for services or items
			 that are medically necessary. Medically necessary is defined as health care
			 services that "are appropriate, in terms of type, amount, frequency, level,
			 setting, and duration to the beneficiary's diagnosis or condition". Medically
			 necessary care must be consistent with generally accepted practice parameters
			 as recognized by health care providers in the same or a similar general
			 specialty as typically treat or manage the diagnosis or condition, and help
			 restore or maintain the claimant's health; or prevent deterioration or palliate
			 the claimant's condition.