Md. Code Regs. 14.09.08.03

Current through Register Vol. 51, No. 24, December 2, 2024

Section 14.09.08.03 - Calculation of the Maximum Reimbursement Allowable

A. For medical services and treatment provided before August 31, 2001, the MRA shall be the fees set forth in the Official Maryland Workers' Compensation Medical Fee Guide (1995). For anesthesiology services, the MRA is calculated by adding the Time Units and Base Units/Basic Value and multiplying that sum by a conversion factor: MRA = (Time Units + Base Units) x Conversion Factor.

B. For medical services and treatment provided between August 31, 2001, and August 31, 2004, the MRA shall be calculated by increasing the fees set forth in the Official Maryland Workers' Compensation Medical Fee Guide (1995) by 4 percent.

C. For medical services and treatment provided between September 1, 2004, and January 31, 2006, the MRA shall be calculated by multiplying the MRR by a percentage multiplier as follows:

(1) The MRR is obtained from the Medicare Physician Fee Schedule by utilizing 2004 for the year, Maryland for the state, Baltimore and Surrounding Counties for the locality, the applicable CPT code and any CPT modifier;

(2) The MRA is calculated by multiplying the MRR by 109 percent; and

(3) For anesthesiology services, the MRA is calculated by adding the Time Units and Base Units/Basic Value, multiplying that sum by the CMS 2004 conversion factor multiplied by 109 percent: MRA = (Time Units + Base Units) x CMS 2004 Conversion Factor x 109 percent.

D. For medical services and treatment provided between February 1, 2006, and March 24, 2008, the MRA shall be calculated by multiplying the MRR by a percentage multiplier as follows:

(2) The MRA is calculated by multiplying the MRR by the specified percentage multiplier:

(a) For anesthesiology services, the MRA is calculated by adding the Time Units and Base Units/Basic Value, multiplying that sum by the CMS 2004 conversion factor multiplied by 109 percent;

(b) For orthopedic and neurological surgical procedures, excluding minor procedures, the MRA is calculated by multiplying the MRR by 144 percent; and

(c) Except as otherwise provided, the MRA for all other medical services and treatment is calculated by multiplying the MRR by 109 percent.

E. After March 24, 2008.

(1) For medical services and treatment provided after March 24, 2008, the Commission shall utilize the current calendar year CMS Resource Based Relative Value Scale (RBRVS), exclusive of any Federal Budget Neutrality Adjustment Factor or CMS conversion factor, as the basis for calculating the MRA.

(2) The non-facility MRA shall be calculated by multiplying each RBRVS relative value unit (RVU) by each corresponding GPCI, adding those sums, and then multiplying that total by the Maryland specific conversion factor (MSCF) as follows: Non-facility MRA = ((Work RVU x Work GPCI) + (Transitioned Non-Facility PE RVU x PE GPCI) + (MP RVU x MP GPCI)) x MSCF.

(3) The facility MRA shall be calculated by multiplying each RBRVS RVU by each corresponding GPCI, adding those sums, and then multiplying that total by the MSCF as follows: Facility MRA = ((Work RVU x Work GPCI) + (Transitioned Facility PE RVU x PE GPCI) + (MP RVU x MP GPCI)) x MSCF.

(4) For anesthesiology services, the MRA shall be calculated by adding the Time Units and Base Units and multiplying that sum by the MSCF: MRA = (Time Units + Base Units) x MSCF.

(5) In calculating the MRA, the following MSCFs apply:

(a) For anesthesiology services, the MSCF is $19.39;

(b) For orthopedic and neurological surgical procedures, MSCF is $53.77; and

(c) For all other medical services and treatment, except as otherwise provided, the MSCF is $40.70.

F. Ambulatory Surgical Centers.

(1) For medical services and treatment provided at an ASC between September 1, 2004, and January 31, 2006, the MRA is calculated by multiplying the CMS 2004 ASC group payment rate by 109 percent.

(2) For medical services and treatment provided at an ASC between February 1, 2006, and March 24, 2008, the MRA is calculated by multiplying the 2004 CMS ASC group payment rate by 125 percent.

(3) For medical services and treatment provided at an ASC on, or after, March 24, 2008, the MRA is calculated by multiplying the current calendar year ASC MRR by 125 percent.

G. MSCF Annual Adjustment.

(1) Beginning January 1, 2009, an adjustment shall be made to the prior year's MSCFs and percentage multiplier (for ASCs).

(2) The MSCFs for the following year shall be calculated by multiplying the MSCFs in effect on November 1 of the current year by the percentage change in the first quarter MEI of the current year, as published on November 1 of the current year, and adding that amount to the current year's MSCFs.

(3) The percentage multiplier for the following year shall be calculated by multiplying the percentage multiplier in effect on November 1 of the current year by the percentage change in the first quarter MEI of the current year, as published on November 1 of the current year, and adding that amount to the current year's percentage multiplier.

(4) The resulting figures shall be utilized as the new MSCF and percentage multiplier for the following year for the purpose of calculating the MRA under §§E and F of this regulation.

(5) The Commission shall post the new MSCFs and percentage multiplier on its website by December 1.

(6) The resulting new MSCFs and percentage multiplier shall be effective January 1 of the following year.

(7) The Commission shall review the annual adjustment process every 5 years to assure that reimbursement rates are neither inadequate nor excessive.

Md. Code Regs. 14.09.08.03

Regulation .03F amended as an emergency provision effective April 4, 2008, (35:9 Md. R. 895); amended permanently effective September 8, 2008 (35:18 Md. R. 1501)
Regulation .03G amended effective March 5, 2012 (39:4 Md. R. 338)
Regulations .03 adopted effective March 24, 2008 (35:6 Md. R. 699)