April 1, 2021 Medical and Dental Fee Schedules Updates
Notable changes to the 2021 Medical and Dental Fee Schedules:
- Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes were updated with code additions, deletions and revisions in accordance with the American Medical Association (AMA) and the American Dental Association (ADA). Healthcare Common Procedure Coding System (HCPCS) codes maintained by CMS were updated.
CPT and CDT maximum allowable reimbursements (MAR) have been recalculated.
- Certain services noted with a star icon are eligible to be provided via telemedicine. The MAR for services provided via telemedicine is the same as for services provided in an office or facility.
Home Health Services hourly rates have been updated:
Registered Nurse (RN)
$53.76 per hour weekday
$62.96 per hour weekend and holiday
Licensed Practical Nurse (LPN)
$39.93 per hour weekday
$46.08 per hour weekend and holiday
Certified Nurse Assistant/Personal Care Attendant (CNA/PCA)
$26.43 per hour weekday
$30.22 per hour weekend and holiday
Non-credentialed Care, Including Family Members
$11.12 per hour, with a maximum of 12 hours per day
When care is provided for less than four hours, the allowed rate will be per visit, as indicated below:
• $138.49 per visit Registered Nurse
• $113.30 per visit Licensed Practical Nurse
• $70.49 per visit Certified Nurse Assistant or Personal Care Attendant
• Physical Therapists, Occupational Therapists and Speech-Language Therapists are reimbursed according to the fee schedule for CPT codes provided in Section X, General Medicine Services, and Section XI, Physical Medicine Services plus $37.06 per visit.
- Ambulance and Non-Emergency Transportation reimbursement rates have been updated.
- Anesthesia conversion factor has been updated to $40.81.
- Inpatient Medicare severity diagnosis-related group (MS-DRG) codes have been updated to version 38, with a base rate increase.
- Pharmaceutical: Both brand name and generic pharmaceuticals are reimbursed at the average wholesale price (AWP) in the Medi-Span Directory. Dispensing fees have been updated to $4.51 for brand name and $6.76 for generic. (See Georgia Workers’ Compensation Medical Fee Schedule for additional guidelines.)
Additional Medical Fee Schedule Information:
- ICD-10-CM/PCS diagnosis and procedure coding has been adopted by the State Board of Workers’ Compensation to coincide with the Centers for Medicare and Medicaid Services’ (CMS) implementation date of October 1, 2015.
- Outpatient Services - Hospital/ASC Section: The Medicare outpatient prospective payment system (OPPS) reimbursement model, with state-specific guidelines, remains as the billing and payment methodology.
- Ambulatory surgery centers are required to be Medicare certified effective August 1, 2013.
- Functional Capacity Evaluations (FCE01): Not to exceed $800.00.
- Physician Testimony/Deposition reimbursement: $600.00 for the first hour and $150.00 for each additional 15 minutes.
- Medical record copy reimbursement rates:
Medical record copy charges under a workers’ compensation claim shall be billed at thirty dollars ($30), plus sales tax (if applicable), and actual cost for postage to mail the documents per request. This fee shall cover any request of up to 150 copied pages, and includes any costs associated with research, retrieval, and certification of the records or information requests.
Any request that exceeds 150 copied pages shall be billed at twenty cents ($0.20) per page, or image if on CD or other electronic storage device that allows electronic retrieval, or copies made from microfilm, and shall include any costs associated with research, retrieval, and certification of the records or information requested. No additional fee beyond the twenty-cent ($0.20) per-page charge shall be billed for requests over 150 pages other than actual cost for postage to mail the documents per request and sales tax (if applicable).
Providers who use a medical record company to make and provide copies of medical records must ensure that reimbursement requirements are followed in accordance with the above fee schedule guidelines. Radiograph copies, either by film, CD, or digital, shall be reimbursed at $9.50 per image.
A maximum allowable fee of $5.00 may be charged only if a medical record search results in no medical records found as requested. However, documentation (such as a computer screen printout or certification that no record(s) have been found) identifying specifically that no records were found for that request must be provided with the bill. No other charges shall be reimbursable beyond this medical record copy fee schedule.
- Supplies, DME, prosthetics and orthotics, and rental equipment reimbursement:
Medical supplies (e.g., sterile trays) provided by the physician or other medical provider over and above those usually included with the office visit (e.g., Band-Aids and cotton swabs) or other services rendered may be listed separately using CPT code 99070. Medical supplies and durable medical equipment are reimbursed at cost times 1.5 plus $4.00 for handling fee charges. Charges greater than $50.00 must be accompanied by a copy of the wholesale vendor invoice(s) showing the actual cost of the item. Certain procedures include supplies; therefore, CPT code 99070 would not be reported. Custom-made orthotics/prosthetics and rental equipment are exempt from the supplies and equipment reimbursement formula; however, usual, customary, and reasonable charges will apply.
- The most current CMS 1500 billing form, version 2/12, is adopted in the Medical Fee Schedule, and the ADA Dental Claim Form © 2012 has been adopted in the Dental Fee Schedule.