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WCA Medical Advisory Committee Meeting

WCA Medical Advisory Committee Meeting. 2009 Physician Fee Schedule & Topics August 20, 2009. Topics of Interest. Physician Fee Schedule Methodology Change List Highlights Overall Pricing Changes Anesthesiology Unit Amount “Disability” Rating Codes, IME Code Ambulance Service Cost Matrix.

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WCA Medical Advisory Committee Meeting

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  1. WCA Medical Advisory Committee Meeting 2009 Physician Fee Schedule & Topics August 20, 2009

  2. Topics of Interest • Physician Fee Schedule Methodology • Change List Highlights • Overall Pricing Changes • Anesthesiology Unit Amount • “Disability” Rating Codes, IME Code • Ambulance Service Cost Matrix Economic Research Bureau Workers' Compensation Administration

  3. Methodology Process Economic Research Bureau Workers' Compensation Administration

  4. Considerations in Favor of Adopting Regional Pricing Methodology • Inconsistencies in local insurer billing data. • Missing data pieces. • Lag time in billed charge data. • Elimination of BRs (More pricing availability). • Narrows research on most troubling codes. • Ensure that New Mexico pricing is not the lowest in the region. Economic Research Bureau Workers' Compensation Administration

  5. Overall Criteria for CPT Amount Changes • New CPTs: Existing data for assigning amount. The Greater of Medicare Pricing/Medicaid Pricing or Regional Pricing at 60th percentile. • Existing CPTs: Check to ensure code is higher than the regional minimum. If not, then adjust to the highest of the regional 60th or Medicaid/care. Check to ensure code is lower than 80th or Medicaid/care. Adjust to highest amount. • Delete CPTs no longer supported by AMA. • If CPT changes are over (+/-) 5%, check billed data sources. • Public Review of Codes and adjust based on commercial billed data sources. Economic Research Bureau Workers' Compensation Administration

  6. Methodology for Adjusting New CPTs • For new CPT codes established by the AMA, assign the greater of the Medicare/Medicaid 2009 or Regional 60th percentile amount. • For new CPT codes established by the AMA that do not have a Medicare/Medicaid 2009 or Regional amount, assign BR to the CPT. Economic Research Bureau Workers' Compensation Administration

  7. Frequency of New CPTs & BRs by Family in Change List Economic Research Bureau Workers' Compensation Administration

  8. Criteria for Assigning Prices to HistoricalBRs • Assign the greater of the Medicaid/Medicare 09 or the Regional 60th percentile amount to historical BRs. • If a historical BR does not have a Regional 60th percentile but has either a Medicaid/Medicare 09 price, assign the Medicaid/Medicare 09 price to the historical BR. Economic Research Bureau Workers' Compensation Administration

  9. Frequency of Historical BRs in Change List by Family Economic Research Bureau Workers' Compensation Administration

  10. Criteria for Making Upward Adjustments to the Maximum Allowable Amount If a current maximum allowable amount falls below Medicare/Medicaid 09 or theregional minimum, adjust the maximum allowable amount to the greater of the Medicare/Medicaid 09 or Regional 60th percentile amount. Economic Research Bureau Workers' Compensation Administration

  11. Frequency of CPTs Adjusted Upward by Family Economic Research Bureau Workers' Compensation Administration

  12. Criteria for Making Downward Adjustments to the Maximum Allowable Amount If a current maximum allowable amount is above the Regional 80th percentile, adjust the amount to the greater of Medicare/Medicaid 09 or Regional 80th percentile amount. Economic Research Bureau Workers' Compensation Administration

  13. Frequency of CPTs Adjusted Downwardby Family Economic Research Bureau Workers' Compensation Administration

  14. Summary of Adjusted CPTs by Frequency Economic Research Bureau Workers' Compensation Administration

  15. Regional Comparison of High Frequency WC CPTs (Evaluation & Management) Economic Research Bureau Workers' Compensation Administration

  16. Regional Comparison of High Frequency WC CPTs (Surgery) Economic Research Bureau Workers' Compensation Administration

  17. Regional Comparison of High Frequency WC CPTs (Radiology) Economic Research Bureau Workers' Compensation Administration

  18. Regional Comparison of High Frequency WC CPTs(Pathology & Laboratory ) Economic Research Bureau Workers' Compensation Administration

  19. Regional Comparison of High Frequency WC CPTs (Medicine) Economic Research Bureau Workers' Compensation Administration

  20. Change List* Cost Differential Analysis by Family(PFS 2008 to PFS 2009) * 62 CPT codes in Change List with frequency history used in this analysis Economic Research Bureau Workers' Compensation Administration

  21. Total Cost Differential Analysis by Family(PFS 2008 to PFS 2009) * CPT codes with experience history (1,462 total) used in this analysis Economic Research Bureau Workers' Compensation Administration

  22. Medical Expenditures by Category2000-2008 Economic Research Bureau Workers' Compensation Administration

  23. “Disability” Rating and IME Codes Economic Research Bureau Workers' Compensation Administration

  24. Analysis of “Disability” Rating and IME Codes Economic Research Bureau Workers' Compensation Administration

  25. Ambulance Services Economic Research Bureau Workers' Compensation Administration

  26. Anesthesia Economic Research Bureau Workers' Compensation Administration

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