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.