Your Certification Made Simple

“POC” means “percent of actual charge.” For instance, 68 POC means that fee is paid at 68% of the actual charge.

Effective January 31, 2015, and excluding those exceptions mandated in the Workers’ Compensation Act plus CPT Code 99080 (used for the physicians form), the fee schedules were populated with actual fee dollar amounts based on relative value units from the Centers for Medicare and Medicaid Services (CMS) and conversion factors calculated from Delaware workers’ compensation data. Whenever one of two elements – 1) a CMS relative value or alternative relative value source; and 2) enough data to calculate a conversion factor – used in the calculation does not exist, then the paid amount for that health care treatment or service is determined using a percent of charge that reflects the 2015 reduction mandated in 19 Del. C. §2322B. The percentages of charge for health care treatment or services not itemized in the fee schedules are as follows:

• Professional services, HCPCS – 53.7 POC
• Laboratory and pathology – 53.7 POC
• Radiology – 53.7 POC
• Dental services – 53.7 POC
• Independently operated diagnostic testing facility – 53.7 POC
• Hospital outpatient – 47.4 POC
• Ambulatory surgery centers – 50.6 POC for geozip 197/198 and 52.5 POC for geozip 199

Pursuant to 19 DE Admin Code 1341, Section 2.0, “Geozip” means the geographical area used to determine the “Delaware specific geographically adjusted factor” mandated in 19 Del.C. §2322B(a).

Modifiers augment CPT codes to more accurately describe the circumstances of services provided. When applicable, the circumstances should be identified by a modifier code: a two-digit number placed after the usual procedure code. If more than one modifier is needed, place modifier 99 after the procedure code to indicate that two or more modifiers will follow. Some modifier descriptions in this fee schedule have been changed from the CPT language.

The OWC adopted the National Correct Coding Initiative as the review standard for bundling edits, pursuant to 19 DE Admin Code 1341, Section 4.1.5.

You may find follow-up days (FUDS) listed as a column in the itemized fee schedule. In addition, 19 DE Admin Code 1341, Section 4.1.5 cites the source used.

6a. General Information

House Bill 373, signed into law on July 15, 2014, mandated the Workers’ Compensation Oversight Panel (Panel) to create a fee schedule based on the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) relative values. The regulations promulgated to support HB373 provide the frame work for the new fee schedules (professional services; ambulatory surgery centers, hospital outpatient facilities and hospital inpatient facilities) are available here.

Pursuant to 19 Del. C. §2322B(5), “the payment system will be adjusted yearly based on percentage changes to the Consumer Price Index-Urban, U.S. City Average, All Items, as published by the United States Bureau of Labor Statistics. Notwithstanding the annual CPI-Urban increase permitted by this paragraph, no individual procedure in Delaware paid for through the workers’ compensation system (as identified by HCPCS level 1 or level 2 code) shall be reimbursed at a rate greater than 200% of that reimbursed by the federal Medicare system, provided that radiology services may be reimbursed at up to 250% of the federal Medicare reimbursement and surgery services may be reimbursed at up to 300% of the federal Medicare reimbursement.”

6b. Anesthesia Methodology

Anesthesia is paid pursuant to 19 DE Admin Code 1341, Section 4.20, which can be read here. Use CMS base units, which are available to download here.

Effective January 31, 2024, the Conversion Factor to be used for geozip 197-198, is $80.14 (eighty dollars fourteen cents) per unit and for geozip 199, it is $60.91 (sixty dollars ninety-one cents) per unit.

6c. Pharmacy

Pharmacy is paid pursuant to 19 DE Admin Code 1341, Section 4.13, which you may find at https://dowc.optum.com/info.asp?page=rules#413. The pharmacy fee schedule calculations are as follows: the Average Wholesale (AWP) for the National Drug Code (NDC) for the prescription drug or medicine on the day it was dispensed minus thirty one point nine percent (31.9%) plus a dispensing fee of three dollars twenty-nine cents ($3.29) for brand name drugs or medicines, or minus thirty-eight percent (38.0%) plus a dispensing fee of four dollars ten cents ($4.10) for generic drugs or medicines. These revisions were put into place in the revised fee schedule effective 01/31/2018.

6d. Revenue Neutral Instructions

Pursuant to 19 DE Admin Code 1341, Section 4.3.3, “…The Department of Labor will publish to its web site additional special instructions associated with the revenue neutral fee conversion, where applicable.”

6e. Conversion Factors for Facilities

19 DE Admin Code 1341, Sections 4.6.4, 4.6.6, and 4.9.3, which you may find at https://dowc.optum.com/info.asp?page=rules#46, contain the methodology used to create the ambulatory surgery center, hospital outpatient, and hospital inpatient itemized fee schedules. Although you must use the fees in the schedules provided at https://dowc.optum.com/download.asp, the regulation also requires the Department of labor to publish on its web site “an appropriately calculated conversion factor” for these facilities. The conversion factors for each geozip are as follows:

• • Ambulatory Surgery Centers
    • Geozip 197, $151.533, conversion factor
    • Geozip 199, $136.25, conversion factor
  • Hospital Outpatient
    • Geozip 197, $177.257, conversion factor
    • Geozip 199, $200.037, conversion factor
  • Hospital Inpatient
    • Geozip 197, $9204.204, conversion factor
    • Geozip 199, $11154.581, conversion factor

6f. Specialty Hospitals, such as Rehabilitation Hospitals

19 DE Admin Code 1341, Section 4.9.5, which you may find at https://dowc.optum.com/info.asp?page=rules#46, contains the methodology for calculating these fees and says the Department of Labor will publish to its web site, “the average percentage of acute care hospitals above Medicare,” which is a value needed for the calculation. That number for each geozip is as follows:

• Geozip 197, the percentage to Medicare is 145.2%
• Geozip 199, the percentage to Medicare is 185.5%

6g. Status Indicator Q3 and Addendum M

19 DE Admin Code 1341, Section 4.22.4, Status Indicator Q3, mentions Addendum M, which may be found on the Centers for Medicare and Medicaid Services web site at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS1204971.html.

Please note, you will find fees in the fee schedules for CPT/HCPCS codes that have Status Indicator Q3 because those codes are not always bundled.

Users can find HCPCS reimbursement amounts in the fee schedule.

Yes. The MS-DRGs have been adopted with the current state conversion factors.