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LEGAL NOTICE Notice of Proposed Rulemaking

Public Hearing Pursuant to Chapter 91, Hawaii Revised Statutes (HRS), notice is hereby given that the Department of Labor and Industrial Relations (DLIR) will hold a public hearing to amend Title 12, Chapter 15, Hawaii Administrative Rules (HAR), relating to the Workers’ Compensation Medical Fee Schedule, and billing codes in Exhibit A, Workers’ Compensation Supplemental Medical Fee Schedule. The hearing will be held on the following date, time, and location: HONOLULU, OAHU November 17, 2016, 8:30 a.m. Keelikolani Building 830 Punchbowl Street Rooms 310, 313, and 314 Honolulu, Hawaii 96813 The proposed changes to the Workers’ Compensation Medical Fee Schedule in Title 12, Chapter 15, HAR, and Exhibit A are 1) to implement Act 101, effective June 21, 2016 (SLH 2016), which allows physicians and providers of service other than physicians to transmit a workers’ compensation treatment plan by mail or facsimile to an address or facsimile number provided by the employer; 2) pursuant to section 386-21(c), HRS, which requires the director to update the fee schedule every three years or annually, as required; and 3) pursuant to Act 97 (SLH 2013) which required the State Auditor to assist the Director of Labor and Industrial Relations in the administrative adjustment of the workers’ compensation medical fee schedule.

The proposed changes to the Workers’ Compensation Medical Fee Schedule rules in Title 12, Chapter 15, HAR, include the following:

1. Sections 12-15-32 and 12-15-34, HAR, Workersꞌ Compensation Medical Fee

Schedule, is amended by allowing physicians and providers of service other than physicians (respectively) to transmit a treatment plan by mail or facsimile to an address or facsimile number provided by the employer.

2. Section 12-15-90, HAR, Workers’ Compensation Medical Fee Schedule, is amended by specifying that the Workers’ Compensation Supplemental Medical Fee Schedule, known as Exhibit A, will be dated January 1, 2017.

3. Codes in Exhibit A at the end of Title 12, Chapter 15, Workers’ Compensation Supplemental Medical Fee Schedule are amended.

A copy of the proposed rule changes will be made available for public viewing from the first working day that the legal notice appears in the Honolulu Star-Advertiser, Hawaii Tribune-Herald, West Hawaii Today, The Maui News, and The Garden Island, through the day the public hearing is held, from Monday - Friday between the hours of 8:00 a.m. -

4:00 p.m., at the following locations of the Department of Labor and Industrial Relations, Disability Compensation Division:

830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813 2264 Aupuni Street, Wailuku, Hawaii 96793 75 Aupuni Street, Room 108, Hilo, Hawaii 96720 81-990 Halekii Street, Room 2087, Kealakekua, Hawaii 96750 3060 Eiwa Street, Room 202, Lihue, Hawaii 96766.

A copy of the proposed rules may be viewed at http://hawaii.gov/labor. Copies can also be mailed to any interested party, upon written request to the Department of Labor and Industrial Relations, Disability Compensation Division, 830 Punchbowl Street, Room 209, Honolulu, HI 96813. Please enclose a self-addressed stamped envelope with $.89 postage on it. Interested persons may present written or oral testimony at the time of the public hearing. All persons wishing to submit written testimony are requested to submit 5 copies of their written testimony before the public hearing to the Department of Labor and Industrial Relations, Disability Compensation Division, 830 Punchbowl Street, Room 209, Honolulu, HI 96813, or 5 copies may be submitted to the presiding officer at the public hearing. The public hearing will be continued, if necessary, to a time, date, and place announced at the scheduled hearing. Interested persons unable to attend the public hearing shall submit 5 copies of their written testimony concerning the proposals to the Department of Labor and Industrial Relations, Disability Compensation Division, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813. All submissions for the record must be received at or prior to the scheduled public hearing. Auxiliary aids and services are available upon request by calling the Disability Compensation Division at (808) 586-9151 or by e-mail to “[email protected]”. A request for reasonable accommodations should be made no later than ten working days prior to the needed accommodations. Dated: October 14, 2016 LINDA CHU TAKAYAMA Director Department of Labor and Industrial Relations

http://hawaii.gov/labor

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DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS

Amendments to Chapter 12-15 Hawaii Administrative Rules

Workers’ Compensation Relating to Medical Fee Schedule

August 23, 2016

1. Section 12-15-32, Hawaii AdministrativeRules, is amended to read as follows:

"§12-15-32 Physicians. (a) Frequency and extent of treatment shall not be more than the nature of the injury and the process of a recovery requires. Authorization is not required for the initial fifteen treatments of the injury during the first sixty calendar days.

(b) If the physician believes treatments in additionto that allowed by subsection (a) are required, the physician shall [mail] transmit a treatment plan to the employer by mail or facsimile under separate cover at least seven calendar days prior to the start of the additional treatments to an address or facsimile number provided by the employer. A treatment plan shall be for one hundred twenty calendar days and shall not exceed fifteen treatments within that period. Treatments provided with less than seven calendar days notice are not authorized. A complete treatment plan shall contain the following elements:

(1) Projected commencement and terminationdates of treatment;

(2) A clear statement as to the impression ordiagnosis;

(3) A specific time schedule of measurableobjectives to include baseline measurementsat the start of the treatment plan andprojected goals by the end of the treatmentplan;

(4) Number and frequency of treatments;(5) Modalities and procedures to be used; and(6) An estimated total cost of services.

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Treatment plans which do not include the above specified elements but which are reasonable and necessary may not be denied by the employer, but upon written notification from the employer, the physician shall correct the deficiency(s) and the employer’s liability is deferred as long as the treatment plan remains deficient. Neither the injured employee nor the employer shall be liable for services provided under a treatment plan that remains deficient. Both the front page of the treatment plan and the envelope in which the plan is mailed or the cover sheet if the plan is sent by facsimile shall be clearly identified as a “WORKERS’ COMPENSATION TREATMENT PLAN” in capital letters and in no less than ten point type. (c) A treatment plan shall be deemed received by an employer when the plan is sent by mail or facsimile with reasonable evidence showing that the treatment plan was received.

[(c)](d) The employer may file an objection to the treatment plan with documentary evidence supporting the denial and a copy of the denied treatment plan with the director, copying the physician and the injured employee. Both the front page of the denial and the envelope in which the denial is filed shall be clearly identified as a “TREATMENT PLAN DENIAL” in capital letters and in no less than ten point type. The employer shall be responsible for payment for treatments provided under a complete treatment plan until the date the objection is filed with the director. Furthermore, the employer’s objection letter must explicitly state that if the attending physician or the injured employee does not agree with the denial, they may request a review by the director of the employer’s denial within fourteen calendar days after postmark of the employer’s denial, and failure to do so shall be construed as acceptance of the employer’s denial.

[(d)](e) The attending physician or the injured employee may request in writing that the director review the employer’s denial of the treatment plan. The request for review shall be filed with the director, copying the employer, within fourteen calendar days after postmark of the employer’s denial. A copy of the denied treatment plan shall be submitted with the request for review. Both the front page of the request for review and the envelope in which the request is filed shall be clearly identified

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as a “REQUEST FOR REVIEW OF TREATMENT PLAN DENIAL” in capital letters and in no less than ten point type. For cases not under the jurisdiction of the director at the time of the request, the injured employee shall be responsible to have the case remanded to the director’s jurisdiction. Failure to file a request for review of the employer’s denial with the director within fourteen calendar days after postmark of the employer’s denial shall be deemed acceptance of the employer’s denial.

[(e)](f) The director shall issue a decision, after a hearing, either requiring the employer to pay the physician within thirty-one calendar days in accordance with the medical fee schedule if the treatments are determined to be reasonable and necessary or disallowing the fees for treatments determined to be unreasonable or unnecessary. Disallowed fees shall not be charged to the injured employee.

[(f)](g) The decision issued pursuant to subsection [(e)](f) shall be final unless appealed pursuant to section 386-87, HRS. The appeal shall not stay the director’s decision.

[(g)](h) The psychiatric evaluation or psychological testing with the resultant reports shall be limited to four hours unless the physician submits prior documentation indicating the necessity for more time and receives pre-authorization from the employer. Fees shall be calculated on an hourly basis as allowed under Medicare.

[(h)](i) For physical medicine, treatments may include up to four procedures, up to four modalities, or a combination of up to four procedures and modalities, and the visit shall not exceed sixty minutes per injury. When treating more than one injury, treatments may include up to six procedures, up to six modalities, or a combination of up to six procedures and modalities, and the entire visit shall not exceed ninety minutes.

[(i)](j) Any physician who exceeds the treatment guidelines without proper authorization shall not be compensated for the unauthorized services.

[(j)](k) No compensation shall be allowed for preparing treatment plans and written justification for treatments which exceed the guidelines.

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[(k)](l) Failure to comply with the requirements in this section may result in denial of fees.

[(l)](m) Treatment, prescribed on an in-patient basis in a licensed acute care hospital where the injured employee’s level of care is medically appropriate for an acute setting as determined by community standards, are excluded from the frequency of treatment guidelines specified herein." [Eff 1/1/96; am 1/1/97; am ] (Auth: HRS §§386-21, 386-26, 386-72; 386- ) (Imp: HRS §§386-21, 386-26, 386-27)

2. Section 12-15-34, Hawaii Administrative Rules, is amended to read as follows:

"§12-15-34 Providers of service other than physicians. (a) Frequency and extent of treatment shall not be more than the nature of the injury and the process of a recovery require. Any health care treatment or service performed by a Hawaii licensed or certified provider of service other than a physician shall be directed by the attending physician based on a written prescription signed, dated, and approved by the attending physician. The prescription may authorize up to an initial fifteen treatments of the injury during the first sixty calendar days. For therapists, the prescription may authorize up to an initial twenty treatments of the injury during the first sixty calendar days.

(b) If the attending physician believes treatments in addition to that allowed by subsection (a) are required, the provider of service other than a physician, in lieu of the attending physician, may [mail] transmit a treatment plan for review and approval to the attending physician who shall, after approval, [mail] transmit the treatment plan to the employer by mail or facsimile under separate cover at least seven calendar days prior to the start of the additional treatments to an address or facsimile number provided by the employer. A treatment plan shall be for one hundred twenty calendar days and shall not exceed fifteen treatments within that period. Treatments provided with less than seven calendar days notice are not authorized. A complete treatment plan shall contain the following elements:

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(1) Projected commencement and termination dates of treatment;

(2) A clear statement as to the impression or diagnosis;

(3) A specific time schedule of measurable objectives to include baseline measurements at the start of the treatment plan and projected goals by the end of the treatment plan;

(4) Number and frequency of treatments; (5) Modalities and procedures to be used; and

Treatment plans which do not include the above specified elements but which are reasonable and necessary may not be denied by the employer, but upon written notification from the employer, the physician or the provider of service, with approval by the attending physician, shall correct the deficiency(s) and the employer’s liability is deferred as long as the treatment plan remains deficient. Neither the injured employee nor the employer shall be liable for services provided under a treatment plan that remains deficient. Both the front page of the treatment plan and the envelope in which the plan is mailed or the cover sheet if the plan is sent by facsimile shall be clearly identified as a “WORKERS’ COMPENSATION TREATMENT PLAN” in capital letters and in no less than ten point type.

(c) A treatment plan shall be deemed received by an employer when the plan is sent by mail or facsimile with reasonable evidence showing that the treatment plan was received.

[(c)](d) The employer may file an objection to the treatment plan with documentary evidence supporting the denial and a copy of the denied treatment plan with the director, copying the attending physician, the provider of service and the injured employee. Both the front page of the denial and the envelope in which the denial is filed shall be clearly identified as a “TREATMENT PLAN DENIAL” in capital letters and in no less than ten point type. The employer shall be responsible for payment for treatments provided under a complete treatment plan until the date the objection is filed with the director. Furthermore, the employer’s objection letter must explicitly state that if the attending physician or the

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injured employee does not agree with the denial, they may request a review by the director of the employer’s denial within fourteen calendar days after postmark of the employer’s denial, and failure to do so shall be construed as acceptance of the employer’s denial.

[(d)](e) The attending physician or the injured employee may request in writing that the director review the employer’s denial of the treatment plan. The request for review shall be filed with the director, copying the employer, within fourteen calendar days after postmark of the employer’s denial. A copy of the denied treatment plan shall be submitted with the request for review. Both the front page of the request for review and the envelope in which the request is filed shall be clearly identified as a “REQUEST FOR REVIEW OF TREATMENT PLAN DENIAL” in capital letters and in no less than ten point type. For cases not under the jurisdiction of the director at the time of the request, the injured employee shall be responsible to have the case remanded to the director’s jurisdiction. Failure to file a request for review of the employer’s denial with the director within fourteen calendar days after postmark of the employer’s denial shall be deemed acceptance of the employer’s denial.

[(e)](f) The director shall issue a decision, after a hearing, either requiring the employer to pay the provider of service other than a physician within thirty-one calendar days in accordance with the medical fee schedule if the treatments are determined to be reasonable and necessary or disallowing the fees for treatments determined to be unreasonable or unnecessary. Disallowed fees shall not be charged to the injured employee.

[(f)](g) The decision issued pursuant to subsection [(e)](f) shall be final unless appealed pursuant to section 386-87, HRS. The appeal shall not stay the director’s decision.

[(g)](h) The provider of service other than a physician shall submit reports at least monthly to the attending physician and employer regarding an injured employee’s progress. The preparation and submission of written reports or progress notes to the employer by the provider of service other than a physician are an integral part of the service fee.

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[(h)](i) Treatments may include up to four procedures, up to four modalities, or a combination of up to four procedures and modalities, and the visit shall not exceed sixty minutes per injury. When treating more than one injury, treatments may include up to six procedures, up to six modalities, or a combination of up to six procedures and modalities, and the entire visit shall not exceed ninety minutes. This section applies to providers of service other than physicians including physical therapists, occupational therapists, massage therapists, and acupuncturists.

[(i)](j) Any provider of service other than a physician who exceeds the treatment guidelines without proper authorization shall not be compensated for the unauthorized services.

[(j)](k) No compensation shall be allowed for preparing treatment plans and written justification for treatments which exceed the guidelines.

[(k)](l) Failure to comply with the requirements in this section may result in denial of fees.

[(l)](m) Therapy by physical therapists and occupational therapists, prescribed on an in-patient basis in a licensed acute care hospital where the injured employee’s level of care is medically appropriate for an acute setting as determined by community standards or, prescribed on an out-patient post-surgery basis not to exceed thirty calendar days, are excluded from the frequency of treatment guidelines specified herein." [Eff 1/1/96; am 1/1/97; am ] (Auth: HRS §§386-21, 386-26, 386-72, 386- ) (Imp: HRS §§386-21, 386-26, 386-27) 3. Section 12-15-90, Hawaii Administrative Rules, is amended to read as follows: “§12-15-90 Workers’ compensation medical fee schedule. (a) Charges for medical services shall not exceed one hundred ten per cent of participating fees prescribed in the Medicare Resource Based Relative Value Scale System fee schedule (Medicare Fee Schedule) applicable to Hawaii or listed in exhibit A, located at the end of this chapter and made a part of this chapter, entitled “Workers’ Compensation

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Supplemental Medical Fee Schedule”, dated [January 1, 2011] January 1, 2017. The Medicare Fee Schedule in effect on January 1, 1995 shall be applicable through June 30, 1996. Beginning July 1, 1996 and each calendar year thereafter, the Medicare Fee Schedule in effect as of January 1 of that year shall be the effective fee schedule for that calendar year. (b) If maximum allowable fees for medical services are listed in both the Medicare Fee Schedule and the Workers’ Compensation Supplemental Medical Fee Schedule, dated [January 1, 2011] January 1, 2017, located at the end of this chapter as exhibit A, charges shall not exceed the maximum allowable fees allowed under the Workers’ Compensation Supplemental Medical Fee Schedule, dated [January 1, 2011] January 1, 2017, located at the end of this chapter as exhibit A. (c) If the charges are not listed in the Medicare Fee Schedule or in the Workers’ Compensation Supplemental Medical Fee Schedule, dated [January 1, 2011] January 1, 2017, located at the end of this chapter as exhibit A, the provider of service shall charge a fee not to exceed the lowest fee received by the provider of service for the same service rendered to private patients. Upon request by the director or the employer, a provider of service shall submit a statement to the requesting party, itemizing the lowest fee received for the same health care, services, and supplies furnished to any private patient during the one-year period preceding the date of a particular charge. Requests shall be submitted in writing within twenty calendar days of receipt of a questionable charge. The provider of service shall reply in writing within thirty-one calendar days of receipt of the request. Failure to comply with the request of the employer or the director shall be reason for the employer or the director to deny payment. (d) Fees listed in the Medicare Fee Schedule shall be subject to the current Medicare Fee Schedule bundling and global rules if not specifically addressed in these rules. The Health Care Financing

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Administration Common Procedure Coding System (HCPCS) alphabet codes adopted by Medicare will not be allowed, except for injections and durable medical equipment, unless specifically adopted by the director. The director may defer to a fee listed in the Medicare HCPCS Fee Schedule when a fee is not listed in the Workers’ Compensation Supplemental Medical Fee Schedule, Exhibit A. (e) Providers of service will be allowed to add the applicable Hawaii general excise tax to their billing.” [Eff 1/1/96; am 1/1/97; am 11/22/97; am 12/17/01; am 12/13/04; am 11/6/06; am 12/14/07; am 2/28/11; am 12/30/13; am ] (Auth: HRS §§386-21, 386-26, 386-72) (Imp: HRS §§386-21, 386-26)

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4. Material, except source notes, to be repealed is bracketed. New material is underscored. 5. Additions to update source notes to reflect these amendments are not underscored. 6. These amendments to Title 12, Chapter 15, Hawaii Administrative Rules, relating to the Hawaii Workersꞌ Compensation Medical Fee Schedule shall take effect ten days after filing with the Office of the Lieutenant Governor. I certify that the foregoing are copies of the rules drafted in the Ramseyer format, pursuant to the requirements of section 91-4.1, Hawaii Revised Statutes, which were adopted on (date to be inserted upon adoption) and filed with the Office of the Lieutenant Governor. ____________________________ Director APPROVED AS TO FORM: __________________________ Deputy Attorney General

CPT only copyright 2015 American Medical Association. CDT copyright 2015 American Dental Association. AllRights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

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EXHIBIT A

Chapters 12-15Hawaii Administrative Rules

WORKERS’ COMPENSATION SUPPLEMENTALMEDICAL FEE SCHEDULE

January 1, 2017

The codes in the Workers’ Compensation Supplemental Medical Fee Schedule are obtained fromthe American Medical Association, the American Dental Association or the State Department ofLabor and Industrial Relations.

The five character codes included in the Workers’ Compensation Supplemental Medical FeeSchedule are obtained from 2016 Current Procedural Terminology (CPT®), copyright 2015 by theAmerican Medical Association (AMA). CPT is developed by the AMA as a listing of descriptiveterms and five character identifying codes and modifiers for reporting medical services andprocedures performed by physicians.

The responsibility for the content of the Workers’ Compensation Supplemental Medical FeeSchedule is with DLIR and no endorsement by the AMA is intended or should be implied. TheAMA disclaims responsibility for any consequences or liability attributable or related to any use,nonuse or interpretation of information contained in the Workers’ Compensation SupplementalMedical Fee Schedule. Fee schedules, relative value units, conversion factors and/or relatedcomponents are not assigned by the AMA, are not part of CPT, and the AMA is not recommendingtheir use. The AMA does not directly or indirectly practice medicine or dispense medical services.The AMA assumes no liability for data contained or not contained herein. Any use of CPT outsideof the Workers’ Compensation Supplemental Medical Fee Schedule should refer to the most currentCPT codes and descriptive terms. Applicable FARS/DFARS apply.

CPT is a registered trademark of the American Medical Association

The five character codes starting with the letter “D” included in the Workers’ CompensationSupplemental Medical Fee Schedule are obtained from Current Dental Terminology 2016,copyright 2015 by the American Dental Association (ADA). CDT is developed by the ADA toachieve uniformity, consistency and accurate reporting of dental treatment.


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TABLE OF CONTENTS

TITLE CODES PAGESURGERY

General 10021 A-4Integumentary System 10160-17004 A-4Musculoskeletal System 20526-29916 A-4Respiratory System 30130-32551 A-6Cardiovascular System 34203-36620 A-6Hemic and Lymphatic System 38220 A-6Digestive System 43753-49653 A-6Urinary System 51600-52000 A-6Female Genital System 57288 A-6Maternity Care and Delivery 59025 A-6Nervous System 62270-64856 A-7Eye and Ocular Adnexa 65205-68815 A-7Auditory System 69200, 69210 A-7Operating Microscope 69990 A-7

RADIOLOGYDiagnostic Radiology (Diagnostic Imaging) 70030-76377 A-7Diagnostic Ultrasound 76512-76942 A-8Radiologic Guidance 77001-77012 A-8Breast, Mammography 77052 A-9Bone/Joint Studies 77073-77080 A-9Nuclear Medicine 78104-78806 A-9

PATHOLOGY AND LABORATORYOrgan or Disease-Oriented Panels 80048-80076 A-9Therapeutic Drug Assays 80156-80299 A-9Consultations (Clinical Pathology) 80500 A-9Urinalysis 81000-81025 A-9Molecular Pathology 81226, 81291 A-9Chemistry 82040-84703 A-9Hematology and Coagulation 85007-85730 A-10Immunology 86003-86803 A-10Transfusion Medicine 86850-86927 A-10Microbiology 87015-87899 A-10Surgical Pathology 88300-88342 A-11Other Procedures 89051, 89060 A-11

MEDICINEVaccines, Toxoids 90636-90746 A-11Psychiatry 90791 90847 A-11Biofeedback 90901 A-11Gastroenterology 91035, 91110 A-11Ophthalmology 92002-92286 A-11Special Otorhinolaryngologic Services 92511-92611 A-11Cardiovascular 93000-93458 A-12Noninvasive Vascular Diagnostic Studies 93880-93979 A-12Pulmonary 94002-94762 A-12Allergy and Clinical Immunology 95044 A-12Neurology and Neuromuscular Procedures 95810-95972 A-12Central Nervous System Assessments/Tests 96101 A-12Health and Behavior Assessment/Intervention 96150, 96152 A-12


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Hydration, Therapeutic, Prophylactic, DiagnosticInjections and Infusions, and Chemotherapy andOther Highly Complex Drug or Highly ComplexBiologic Agent Administration 96360-96376 A-13

Physical Medicine and Rehabilitation 97012-97605 A-13Acupuncture 97810-97814 A-13Chiropractic Manipulative Treatment 98940 A-13Special Services, Procedures and Reports 99000-99090 A-13Qualifying Circumstances for Anesthesia 99100-99140 A-13Moderate (Conscious) Sedation 99144 A-13Other Services and Procedures 99173, 99183 A-13

DENTAL SERVICESDiagnostic D0120-D0470 A-13Preventive D1110 A-13Restorative D2160-D2962 A-14Endodontics D3310 A-14Periodontics D4211, D4266 A-14Prosthodontics, Removable D5110-D5820 A-14Implant Services D6010-D6104 A-14Prosthodontics, Fixed D6240-D6750 A-14Oral and Maxillofacial Surgery D7140-D7953 A-14Adjunctive General Services D9110-D9942 A-14

EVALUATION AND MANAGEMENTOffice or Other Outpatient Services 99201-99211 A-14Hospital Observation Services 99217, 99225 A-14Hospital Inpatient Services 99222, 99231-99239 A-14Consultations 99241-99255 A-15Emergency Department Services 99281-99285 A-15Critical Care Services 99291, 99292 A-15Nursing Facility Services 99308-99310 A-15Prolonged Services 99354, 99358 A-15Case Management Services 99366, 99367 A-15Preventive Medicine Services 99395, 99406 A-15Non-Face-to-Face Services 99441-99443 A-15Special Evaluation and Management Services 99456A, 99456B A-15


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SURGERY

General

Maximum Maximum MaximumCode Fee Code Fee Code Fee10021 $174.73

Integumentary System

10160 $162.9011000 $69.9311011 $651.0711012 $896.4611043 $297.2711044 $444.8911045 $56.8211055 $60.5711101 $41.6411720 $39.4911750 $272.9311760 $266.5912001 $167.7212002 $184.3312004 $212.4412005 $260.5412007 $364.6312011 $184.1712013 $203.98

12014 $231.2012015 $279.8412016 $340.0112031 $290.0512032 $380.3812041 $306.4312042 $357.6112051 $319.7212052 $376.6112054 $452.3813101 $483.7213121 $551.4013132 $701.6713133 $221.9813152 $681.3713153 $235.4214040 $931.9914041 $1,202.8715002 $422.38

15003 $97.7615004 $496.3015100 $1,049.1715101 $241.8915120 $1,073.6615121 $322.7415260 $1,221.2715273 $446.6515738 $1,747.1916000 $84.9716020 $108.9316025 $186.2316030 $230.0517000 $86.5117003 $14.0417004 $235.60

Musculoskeletal System

20526 $96.2020550 $74.9920551 $81.1320552 $76.9620553 $82.6320600 $68.5120605 $73.3220610 $93.7920612 $78.6020650 $252.7620670 $594.8720694 $546.6020900 $607.0420902 $602.6020924 $643.2920926 $552.3520930 $150.4920931 $189.6720936 $177.7720937 $252.5320974 $101.8121320 $334.1121365 $1,522.1821390 $1,259.1021395 $1,318.80

21406 $711.5721407 $927.4821408 $1,174.2821470 $1,690.2822551 $2,800.2822552 $622.9422554 $1,950.2022558 $2,164.0022585 $518.0622600 $1,723.6122610 $1,701.3022612 $2,226.3722614 $581.9722630 $2,160.9322632 $445.0122633 $3,021.8322634 $753.1522830 $1,129.6122840 $1,076.5022842 $1,022.3622845 $1,202.2322851 $609.6822852 $953.9022855 $1,427.2022856 $2,501.51

23120 $766.6523130 $849.5123184 $1,035.5123350 $198.0323405 $859.9023410 $1,217.4223412 $1,254.9923420 $1,452.6523430 $1,031.6323440 $1,027.7623455 $1,482.4523466 $1,588.5623500 $287.1823515 $857.6023540 $286.9423570 $292.3823600 $411.6023615 $1,124.9023616 $1,936.6323620 $328.1923630 $923.2823650 $390.0523700 $268.9824120 $694.1524220 $233.60

Maximum Maximum MaximumCode Fee Code Fee Code Fee


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24305 $728.6624340 $812.0424341 $916.3924342 $1,115.6724344 $1,330.3624357 $666.6024358 $791.2324359 $968.2424366 $952.0424500 $436.8224505 $622.6424515 $1,200.2724600 $465.0524605 $571.4024650 $337.8124685 $932.9024900 $971.5825000 $500.5425024 $939.9825105 $708.9225111 $456.7625246 $237.3525259 $526.3825260 $965.3225270 $788.6425290 $792.8225295 $806.2125310 $964.2525320 $1,231.6225337 $1,164.6725390 $1,142.8725400 $1,237.6525405 $1,495.5625440 $1,055.4825447 $1,097.4225500 $340.3625505 $626.6025545 $887.3425574 $871.8525575 $1,232.8125605 $750.3525607 $1,021.4725608 $1,182.7225609 $1,482.5925622 $380.6825628 $936.6225630 $387.1225680 $594.5426035 $1,093.8226055 $736.9526075 $448.7426080 $511.1826105 $467.5526110 $433.5026113 $749.1926145 $711.8926320 $473.5926340 $459.5826350 $985.6026356 $1,390.20

26358 $1,232.7026370 $1,084.4726410 $822.3026418 $766.7926426 $842.0626432 $663.2926433 $701.5926440 $828.8426445 $787.8926540 $905.3726541 $1,091.6326548 $1,034.7426567 $894.5126605 $415.2426608 $644.3326615 $698.5426720 $274.1326725 $430.9126727 $620.4326735 $727.0626750 $233.3126756 $525.9926770 $341.9926860 $747.5026910 $946.1826951 $803.1126952 $855.2927093 $276.2327096 $332.1327130 $2,129.2327216 $1,292.0927217 $1,410.0427227 $2,215.5927228 $2,555.8027235 $1,278.1027236 $1,637.2827244 $1,709.0227245 $1,853.4127248 $986.8527265 $524.2127340 $490.3127345 $648.7927347 $668.7627350 $898.4427370 $233.3627380 $801.3227385 $878.4127405 $944.8127416 $1,455.0527430 $1,030.4827446 $1,621.2927447 $2,246.9627457 $1,340.5327486 $1,969.8527487 $2,493.2927506 $1,824.3627520 $409.6027524 $1,038.2927530 $479.5027535 $1,246.89

27536 $1,535.0827560 $438.2727570 $210.9127590 $1,121.5627603 $691.4627619 $791.8727640 $1,254.4027648 $230.6727650 $991.8927652 $1,016.2027658 $540.6527665 $598.4227675 $671.9727680 $600.1427687 $651.3927695 $706.1827698 $938.7527720 $1,241.7627750 $455.4427758 $1,202.2127759 $1,428.7927760 $426.9627766 $875.7127780 $374.0227786 $393.8727792 $885.8827808 $420.3627814 $1,124.2327823 $1,345.7127827 $1,498.7827828 $1,727.1227829 $827.0127840 $452.9927842 $601.2827882 $883.5028002 $599.3928122 $816.3328192 $585.6828238 $866.6528300 $943.8228400 $322.3428415 $1,510.9328430 $303.1528445 $1,358.7428450 $282.4828470 $288.9528485 $679.8128510 $153.7329065 $121.4029075 $110.0429085 $118.5629105 $109.6429125 $83.8629126 $96.9729131 $67.2629200 $66.7029240 $73.2829260 $62.2129280 $62.2629355 $180.20



A-6

29405 $114.0029425 $121.3129505 $104.3129515 $92.3729520 $64.1829530 $65.3729540 $50.3929550 $46.4329580 $67.4229700 $79.9029705 $82.5329805 $608.9229806 $1,440.9329807 $1,418.5929820 $793.8429822 $842.5029823 $920.78

29824 $891.1829825 $833.1129826 $690.0229827 $1,544.1729828 $1,281.0129834 $680.0429835 $692.5529837 $736.8129838 $817.5229845 $803.1429846 $744.3629848 $671.6129867 $1,593.1629871 $730.0429873 $700.6129874 $788.1629875 $737.00

29876 $927.7829877 $887.7829879 $952.5429880 $982.2829881 $916.2329882 $1,002.7029888 $1,471.4529889 $1,545.3129891 $810.9229895 $734.7129897 $774.1729898 $833.4729906 $1,055.3629907 $1,278.8129914 $1,696.2729915 $1,557.5629916 $1,558.39

Respiratory System

30130 $482.4530520 $827.0631500 $166.66

31525 $324.8931570 $479.0231575 $158.95

32551 $262.15

Cardiovascular System

34203 $1,265.6935206 $1,115.5736140 $704.7936245 $1,846.3536246 $1,701.47

36247 $2,718.8236410 $26.5836415 $6.3236430 $55.2336556 $390.26

36569 $443.4236592 $44.6236600 $40.7136620 $78.69

Hemic and Lymphatic Systems

38220 $251.60

Digestive System

43753 $33.0845380 $617.3549505 $685.3549507 $803.1549520 $820.8949525 $743.66

49560 $966.5449561 $1,150.1249568 $333.1449585 $585.9149587 $671.3649650 $582.01

49651 $723.6849652 $1,084.7549653 $1,453.51

Urinary System

51600 $300.4251700 $124.4351702 $121.30

51726 $434.8951741 $136.9251784 $283.12

51785 $314.4151798 $30.6452000 $284.91

Female Genital System

57288 $1,148.17

Maternity Care and Delivery

59025 $78.09



A-7

Nervous System

62270 $203.6262290 $440.5762310 $306.8862318 $340.8462319 $282.3362362 $621.8562367 $53.9262368 $82.9262369 $187.5262370 $194.7863030 $1,383.8363035 $292.0163042 $1,728.8463045 $1,740.0963047 $1,619.5563048 $322.7763075 $2,020.6663081 $2,473.8163082 $404.5563655 $1,127.5363662 $1,036.74

63685 $617.7063688 $531.2564405 $149.1764413 $167.5464415 $175.4164417 $180.8064418 $179.6164421 $297.9964425 $176.4564445 $180.6364450 $129.8764479 $434.6564480 $216.8964483 $424.2564484 $213.9764490 $241.5964491 $118.5864492 $118.0764493 $228.1464494 $113.0164495 $114.07

64510 $181.7364520 $252.3964550 $24.2764633 $669.2764634 $310.1564635 $658.1664636 $279.6564640 $276.5664702 $600.0964704 $482.3064708 $682.1764718 $804.7164721 $594.1764772 $709.7564776 $507.6464782 $591.6064831 $865.7764832 $436.5664834 $944.9964856 $1,248.70

Eye and Ocular Adnexa

65205 $72.2465210 $84.9565220 $74.6565222 $94.3665285 $1,398.7565426 $814.7165430 $152.20

65435 $106.0365730 $1,715.2066761 $524.6266850 $1,079.3066984 $1,055.4867036 $1,330.8167145 $684.57

67820 $82.1667917 $850.7768700 $840.6968761 $196.8168810 $373.0568815 $674.86

Auditory System

69200 $153.35 69210 $62.83

Operating Microscope

69990 $305.89

RADIOLOGY

Fees include both the technical and professional components. In the absence of any prior agreement, the professionalcomponent shall be thirty-five percent of the scheduled fee.

Diagnostic Radiology (Diagnostic Imaging)

70030 $46.4770100 $55.4670110 $67.2370140 $52.6170150 $70.7170160 $56.5070200 $72.56

70220 $67.3470250 $60.9870260 $81.5270330 $82.5870336 $822.7770355 $39.5470360 $47.05

70450 $355.1770460 $455.3770470 $559.8770480 $460.0470486 $413.6270491 $504.0970496 $870.81



A-8

70498 $895.3670543 $1,396.3170544 $846.7670547 $873.0770551 $758.0970553 $1,448.0971010 $41.6971020 $53.8871030 $76.2371035 $56.5771100 $53.7971101 $65.4571110 $63.3971111 $90.9371120 $55.6871130 $62.2471250 $460.8971260 $569.1171270 $708.1471275 $802.1171550 $820.5771552 $1,459.4072020 $39.0672040 $62.3072050 $88.1572052 $111.5172070 $57.3772072 $57.8572074 $68.7172080 $59.8872100 $66.0272110 $91.0472114 $120.3372120 $85.0572125 $462.6572128 $461.6572129 $571.9672131 $459.5372132 $571.0872141 $807.2172142 $993.6572146 $786.0072148 $785.37

72149 $986.1272156 $1,419.7672157 $1,411.1572158 $1,401.6472170 $46.6972190 $68.9372192 $439.7372193 $546.7472195 $802.1272197 $1,418.3072200 $49.3772202 $60.9872220 $49.3472265 $278.1272275 $193.0472295 $399.4873000 $49.2273010 $51.9273020 $40.5173030 $50.4873040 $189.3073050 $65.3973060 $49.2373070 $49.0573080 $55.1973085 $171.2473090 $48.7173100 $50.3673110 $60.3973115 $171.0073120 $47.6573130 $54.0873140 $50.1573200 $434.7773201 $501.3173218 $798.5873220 $1,297.2473221 $802.9973222 $979.1773223 $1,384.5673525 $176.3673560 $51.4073562 $59.69

73564 $66.2473565 $55.2973580 $229.6173590 $46.0873600 $48.5073610 $54.3573620 $47.3573630 $53.6273650 $47.4573660 $47.5673700 $435.1073701 $504.3273706 $810.3473718 $761.8273720 $1,297.5073721 $765.6473722 $980.5573723 $1,385.0174000 $44.3374020 $66.8774022 $80.0374150 $437.2474160 $551.3974175 $829.8874176 $538.4174177 $697.6274178 $853.9674181 $828.4474183 $1,427.0074430 $118.3975625 $628.6475710 $634.0975716 $685.0775736 $640.1175774 $489.4075894 $1,357.8975898 $222.4876000 $147.1576001 $182.1876376 $134.9676377 $162.80

Diagnostic Ultrasound

76512 $173.6576514 $26.5976519 $136.1576536 $190.8776700 $218.7976705 $166.7476770 $209.93

76775 $157.9176801 $196.5176815 $145.3176817 $164.0676830 $189.4476856 $188.9476870 $174.62

76881 $190.5876882 $52.2376937 $59.5076942 $253.74

Radiologic Guidance

77001 $178.3477002 $148.68

77003 $130.1177012 $424.76



A-9

Breast, Mammography

77052 $20.82

Bone/Joint Studies

77073 $71.22 77077 $78.24 77080 $169.44

Nuclear Medicine

78104 $436.4878300 $300.3478305 $399.4478306 $443.21

78315 $555.0178320 $462.1178445 $286.6478452 $936.51

78805 $327.5978806 $614.64

PATHOLOGY AND LABORATORY

Organ or Disease-Oriented Panels

80048 $21.2080050 $53.8280051 $16.59

80053 $22.7880061 $41.4280069 $18.65

80074 $101.7580076 $17.66

Therapeutic Drug Assays

80156 $34.4380164 $32.2780176 $33.21

80184 $27.2280185 $31.6180186 $29.81

80197 $32.5480202 $32.2780299 $27.85

Consultations (Clinical Pathology)

80500 $35.04

Urinalysis

81000 $5.0181001 $7.5781002 $6.18

81003 $5.2081005 $5.1281015 $7.14

81025 $15.07

Molecular Pathology

81226 $640.24 81291 $95.53

Chemistry

82040 $11.8682043 $13.8482105 $34.0582140 $34.7382150 $13.1882175 $38.5982247 $12.0082248 $11.9682270 $7.49

82274 $34.9982306 $60.6382310 $12.1482330 $32.4682374 $11.5482375 $29.2782382 $34.9982435 $10.8682465 $10.26

82530 $39.8382533 $40.0882542 $44.5182550 $15.3482553 $27.3882565 $12.0982570 $12.1682607 $35.6782728 $29.42



A-10

82746 $34.9382785 $39.2182803 $45.8782805 $69.9182945 $9.3982947 $9.4082948 $6.4282962 $3.9282977 $17.1383001 $44.1783002 $43.9483003 $39.4983010 $29.8683018 $44.6783036 $22.9283090 $40.0583516 $23.4183525 $27.2183540 $15.3183550 $17.7483605 $25.3783615 $14.4683655 $28.6783690 $16.46

83718 $19.5683721 $22.7183735 $15.9183789 $39.0583861 $35.4883880 $80.9883921 $32.0183930 $15.7583935 $16.0483970 $97.6583986 $6.8483992 $36.2284075 $12.1684100 $11.3784132 $10.8684134 $33.0684146 $46.0684153 $43.6484155 $8.7784156 $8.9484157 $8.7884165 $42.9284270 $38.4184295 $11.43

84300 $11.4984305 $40.4384311 $14.1784315 $5.8484402 $51.7184403 $52.5084436 $16.4384439 $21.4584443 $39.9384450 $12.1784460 $12.6284466 $25.9684478 $13.8284480 $33.5984481 $40.1384482 $37.4384484 $23.4584520 $9.4284550 $10.7484681 $49.4684702 $35.5784703 $18.46

Hematology and Coagulation

85007 $8.1985014 $5.8985018 $5.9085025 $18.3985027 $15.2785045 $9.56

85049 $10.7585240 $42.5385379 $23.7285384 $20.2385460 $14.6185576 $68.76

85610 $9.4285651 $8.3485652 $5.4885670 $13.8185730 $14.14

Immunology

86003 $10.6086038 $30.2886140 $12.1886141 $24.1686160 $28.5786200 $30.7086225 $32.5386235 $36.97

86430 $11.5086431 $13.3886580 $13.6086592 $8.1186677 $34.3986689 $39.3286703 $32.5186704 $28.61

86705 $27.9786706 $25.5186707 $27.4186708 $29.3286709 $26.7486803 $33.79

Transfusion Medicine

86850 $28.3886900 $6.0486901 $7.74

86904 $10.5686920 $45.9586922 $33.57

86927 $29.58

Microbiology

87015 $12.5987040 $20.9987046 $20.1887070 $20.3587071 $18.4287075 $19.2187076 $17.56

87077 $17.5087081 $12.5987086 $16.3887088 $18.5287102 $17.0887103 $18.3787110 $46.45

87116 $24.6087140 $11.3287147 $10.5387181 $4.6687184 $14.0587186 $17.5287205 $10.17



A-11

87206 $12.7287210 $8.6487324 $24.3487340 $20.9387350 $27.3787389 $49.23

87449 $19.1287491 $62.9287517 $87.0187522 $87.0187536 $170.6187591 $70.56

87641 $66.8187804 $24.4087880 $24.7387899 $24.84

Surgical Pathology

88300 $34.1488302 $69.6288304 $87.45

88305 $168.5788311 $31.7988312 $149.21

88331 $155.6588342 $161.40

Other Procedures

89051 $11.20 89060 $29.80

MEDICINE

Fees include both the technical and professional components. In the absence of any prior agreement, the professionalcomponent shall be thirty-five percent of the scheduled fee.

Vaccines, Toxoids

90636 $94.8490714 $24.61

90715 $43.5690732 $73.84

90746 $61.45

Psychiatry

90791 $220.7090792 $206.1090832 $106.27

90834 $142.5990837 $187.2890838 $135.70

90846 $133.7490847 $158.22

Biofeedback

90901 $59.20

Gastroenterology

91035 $689.74 91110 $1,360.49

Ophthalmology

92002 $98.1192015 $59.4292020 $44.0492025 $51.1292060 $81.0292071 $56.0692082 $79.79

92083 $98.1092132 $52.2492133 $65.5392134 $65.7792136 $122.0492225 $35.6192226 $33.30

92235 $176.2392250 $99.9692284 $95.0792285 $41.6892286 $152.57

Special Otorhinolaryngologic Services

92511 $188.74 92526 $109.00 92540 $149.97



A-12

92541 $64.0092542 $62.4992545 $46.8692547 $20.8992548 $138.2492550 $25.2692557 $65.20

92565 $21.5392567 $23.6492568 $22.0392570 $39.5292577 $32.8192587 $67.2692588 $96.29

92591 $105.7292592 $40.7892594 $25.8092595 $44.1392610 $143.9492611 $158.07

Cardiovascular

93000 $34.3893005 $20.7293010 $12.3193015 $140.1693016 $30.1893017 $86.9693018 $21.73

93040 $19.1193042 $10.6593225 $57.7893226 $96.2893227 $38.4093280 $92.0793282 $103.07

93283 $126.7793289 $98.8893306 $409.8493307 $249.9893325 $64.7593351 $407.5193458 $1,367.12

Noninvasive Vascular Diagnostic Studies

93880 $301.2893926 $217.24

93970 $301.9593971 $199.14

93976 $278.3593979 $202.08

Pulmonary

94002 $116.7394003 $88.7194010 $50.7294060 $87.7194640 $28.00

94644 $57.7994645 $20.1294664 $24.1294667 $35.0494726 $79.79

94727 $62.4094729 $80.4794760 $5.8294762 $39.41

Allergy and Clinical Immunology

95044 $9.22

Neurology and Neuromuscular Procedures

95810 $990.5995811 $1,033.8995851 $27.6095852 $22.0595885 $84.6495886 $127.5995907 $127.9195908 $172.08

95909 $188.9695910 $248.4695911 $300.1295912 $351.3995913 $406.4095925 $205.7095926 $194.1795928 $302.55

95929 $308.0395930 $173.2295938 $487.2495939 $743.0795957 $456.6295971 $76.7195972 $135.68

Central Nervous System Assessments/Tests

96101 $107.81

Health and Behavior Assessment/Intervention

96150 $26.94 96152 $26.12



A-13

Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions,and Chemotherapy and Other Highly Complex Drug

or Highly Complex Biologic Agent Administration

96360 $94.7096361 $25.9496365 $110.46

96366 $32.4496367 $52.1096374 $83.70

96375 $35.7796376 $24.24

Physical Medicine and Rehabilitation

97012 $18.9497014 $16.0197024 $8.0297026 $7.30

97033 $33.8897035 $15.6097150 $21.8597532 $32.31

97545 $148.6197546 $49.0197605 $49.55

Acupuncture

97810 $53.2797811 $35.31

97813 $57.2097814 $39.55

Chiropractic Manipulative Treatment

98940 $36.90

Special Services, Procedures and Reports

99000 $8.1799002 $10.8999050 $39.35

99051 $10.7899053 $67.0099058 $25.72

99060 $74.0999090 $48.66

Qualifying Circumstances for Anesthesia

99100 $44.15 99135 $116.12 99140 $71.11

Moderate (Conscious) Sedation

99144 $85.36

Other Services and Procedures

99173 $9.80 99183 $269.15

DENTAL SERVICES

Diagnostic

D0120 $41.82D0140 $52.69D0150 $57.13

D0210 $93.16D0220 $19.27D0230 $15.04

D0274 $48.78D0330 $84.01D0470 $70.63

Preventive

D1110 $68.85



A-14

Restorative

D2160 $118.21D2330 $89.49D2331 $123.15D2332 $153.70

D2335 $177.04D2740 $803.76D2750 $753.82D2752 $712.82

D2940 $71.22D2950 $173.19D2954 $203.75D2962 $715.66

Endodontics

D3310 $461.66

Periodontics

D4211 $211.85 D4266 $382.32

Prosthodontics, Removable

D5110 $993.42D5130 $1,062.41

D5211 $808.92D5212 $862.39

D5820 $390.40

Implant Services

D6010 $1,730.61D6057 $531.67

D6059 $1,111.42D6104 $236.42

Prosthodontics, Fixed

D6240 $736.85 D6245 $725.26 D6750 $756.23

Oral & Maxillofacial Surgery

D7140 $93.49D7210 $189.59

D7880 $480.01D7953 $255.81

Adjunctive General Services

D9110 $77.14 D9940 $386.50D9310 $92.24 D9942 $110.66

EVALUATION AND MANAGEMENT

Office or Other Outpatient Services

99201 $54.5799202 $89.41

99203 $130.8299211 $29.95

Hospital Observation Services

99217 $90.55 99225 $92.41

Hospital Inpatient Services

99222 $164.1899231 $49.8699232 $86.36

99233 $121.6199235 $208.4499236 $265.42

99238 $87.2299239 $130.54



A-15

Consultations

99241 $54.5099242 $89.6899243 $124.0299244 $169.27

99245 $206.7299251 $51.8799252 $80.8099253 $119.78

99254 $171.9999255 $212.99

Emergency Department Services

99281 $37.5299282 $68.64

99283 $112.2599284 $180.91

99285 $265.32

Critical Care Services

99291 $333.95 99292 $160.93

Nursing Facility Services

99308 $80.73 99309 $111.54 99310 $158.61

Prolonged Services

99354 $129.85 99358 $163.03

Case Management Services

99366 $58.9199367 $77.24

Preventive Medicine Services

99395 $121.34 99406 $17.63

Non-Face-to-Face Services

99441 $19.91 99442 $36.89 99443 $54.37

Special Evaluation and Management ServicesMaximum

Code Description Fee99456A* Complex consultation pursuant to Section 386-79, HRS - work related or medical disability

examination by other than the treating physician that includes: completion of a medical history commensurate with the patient’s condition; performance of an examination commensurate with the patient’s condition; formulation of a diagnosis, assessment of capabilities and stability, and calculation of

impairment; development of future medical treatment plan; completion of necessary documentation/certificates and report; and review of records relating to the patient’s condition.First hour ....................................................................................................................................................... $201.24

99456B* Each additional 30 minute increment (an increment must be at least 30 minutes.) ................................. $100.62

*Department of Labor Code

Bundled Services: Certain codes, such as telephone calls, are considered by the Health Care Financing Administration (HCFA) tobe “bundled” services. Bundled services are not payable, nor should they be billed, when performed incidentto or in conjunction with another service even if the other service is performed on a different day. Whenservices that are designated as bundled are denied, the physician may not collect from the patient.

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