Neb. Work. Comp. Ct. 26

As amended through October 23, 2024

Rule 26 - Schedules Of Fees For Medical, Surgical, And Hospital Services

A. The following Nebraska Workers' Compensation Court fee schedules, including the instructions, ground rules, unit values, and conversion factors set out in such schedules, are hereby adopted pursuant to section 48-120(1)(b) of the Nebraska Workers' Compensation Act. Reimbursement for medical, surgical, and hospital services provided pursuant to section 48-120 shall be in accordance with such schedules, except for services covered by the inpatient hospital fee schedules established in section 48-120.04, and except for services covered by contract pursuant to section 48-120(1)(d).

1. Schedule of Fees for Medical Services, effective January 1, 2024.

2. Schedule of Fees for Hospitals and Ambulatory Surgical Centers, effective January 1, 2012.

3. Schedule of Fees for Implantable Medical Devices, effective January 1, 2012.

Such schedules and the inpatient hospital fee schedules established in section 48-120.04 shall be available free of charge on the court's website.

B. Schedule of Fees for Medical Services.

1. The Schedule of Fees for Medical Services shall apply to medical and surgical services provided by physicians and other licensed health care providers within the scope of their respective licenses.

2. The Schedule of Fees for Medical Services shall be established as follows. Adjustments to the schedule shall be made annually thereafter as provided herein, with such adjustments to become effective each January 1.

a. The schedule shall include the Medicare Resource-Based Relative Value Scale (RBRVS) applicable to Nebraska, as reflected in the applicable tables established and published by the federal Centers for Medicare and Medicaid Services (CMS) for the federal Medicare program and geographically adjusted for Nebraska.

b. The schedule shall include the Current Procedural Terminology (CPT) codes in the CMS tables and the relative value units established by CMS for each CPT code in the tables.

c. The schedule shall be adjusted annually to incorporate the CPT codes and relative value units in the then current CMS tables applicable to Nebraska.

d. The schedule may be supplemented with additional CPT codes, relative value units, follow-up days, base values, instructions, ground rules, or other components or factors as determined by the court.

e. The schedule shall include the following service categories:

(i) emergency department services,

(ii) evaluation and management services,

(iii) anesthesia services,

(iv) orthopedic surgery services,

(v) all other surgery services,

(vi) radiology services,

(vii) pathology and laboratory services,

(viii) medicine services, and

(ix) physical medicine services. The specific services and related CPT codes to be included in each service category shall be determined by the court.

f. The conversion factors for the service categories identified in Rule 26,B,2,e shall be determined by applying the annual percentage adjustment of the Medicare Economic Index (MEI) to the previous year's conversion factor for each service category. For purposes of this rule, the MEI means the input price index used by CMS to measure changes in the costs of providing physician services paid under the RBRVS.

3. Services subject to the Schedule of Fees for Medical Services shall be reimbursed at the lower of the fee schedule amount or the provider's billed charge. The fee schedule amount for a particular service shall be determined by first multiplying the relative value unit for the CPT code applicable to the service provided by the dollar conversion factor for the service category in which the code is located. The resulting amount may then be modified by instructions or ground rules for the service category in which the code is located to arrive at the final fee schedule amount. Medical or surgical services not covered under the schedule shall be paid in full unless the payor has evidence that the provider's charge exceeds the regular charge for such service by Nebraska providers.

4. Coding for services subject to the Schedule of Fees for Medical Services shall be in accordance with the CPT manual published by the American Medical Association, and in accordance with the National Correct Coding Initiative (NCCI) established by CMS. A provider shall not fragment or unbundle charges imposed for a service except as consistent with the CPT manual and the NCCI. Coding by a provider may be changed by a workers' compensation insurer, risk management pool, or self-insured employer, or any adjustor, third-party administrator, or other agent acting on behalf of any such workers' compensation insurer, risk management pool, or self-insured employer, only as consistent with the CPT manual and the NCCI and following consultation with the provider.

5. The Schedule of Fees for Medical Services shall not apply to costs and expenses incurred by or on behalf of any party for the purpose of proving or disproving a contested claim, except that X-rays, laboratory services, and other diagnostic tests provided in connection with a medical-legal evaluation shall be subject to the schedule.

C. The Diagnostic Related Group inpatient hospital fee schedule established in section 48-120.04 shall include the following Medicare Diagnostic Related Groups, effective January 1, 2024:

3	85	175	229	453	475	496	520	571	640	870	915	958
27	86	176	240	454	476	497	521	573	641	871	917	964
28	87	184	253	455	477	501	522	574	661	872	918	981
29	89	185	254	458	478	502	534	577	662	880	920	983
30	92	187	271	459	480	505	536	578	663	902	923	987
41	93	189	300	460	481	506	551	580	664	903	927	988
57	95	193	315	463	482	511	552	581	697	904	928
62	103	199	330	464	483	512	556	602	698	905	929
69	113	200	331	465	486	513	558	603	699	906	935
70	117	205	337	467	488	514	559	605	832	907	949
74	158	206	351	468	489	516	560	616	853	908	950
82	164	207	353	470	492	517	561	617	854	909	955
83	166	208	389	472	493	518	562	623	857	913	956
84	167	220	392	474	494	519	563	629	862	914	957

D. For inpatient hospital discharges prior to October 1, 2015, a claim for inpatient trauma services shall mean a claim which has at least one of the following ICD-9-CM diagnosis codes in UB-04 Form Locator 67: Injury codes in the range of 800-959.9, 994.1, 994.7, or 994.8; and either:

1. The patient was admitted to the hospital from the emergency department (UB-04 Form Locator 14 with Priority (Type) of Visit as: 1-Emergency, or 5-Trauma), or

2. The patient was transferred out of the hospital (UB-04 Form Locator 17 with Patient Discharge Status 02-Discharged/transferred to a Short Term General Hospital for Inpatient Care), or

3. The patient was admitted directly to the hospital, bypassing the emergency department (UB-04 Form Locator 14 with Priority (Type) of Visit as: 1-Emergency, or 5-Trauma), or

4. The patient died in the emergency department (UB-04 Form Locator 17 with Patient Discharge Status 20-Expired), or

5. The patient was dead on arrival in the emergency department (UB-04 Form Locator 17 with Patient Discharge Status 20-Expired).

E. For inpatient hospital discharges on or after October 1, 2015, a claim for inpatient trauma services shall mean a claim which has at least one of the following ICD-10-CM diagnosis codes in UB-04 Form Locator 67: Injury codes in the range of M80, M84, S00-S99, T07-T34, T51-T79; and either: