Schedule of medical and hospital fees

              Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
NOTICE The five character codes included in the Schedule of Medical Fees are obtained from Current Procedural Terminology, (CPT7), copyright 2010 by the American Medical Association (AMA). CPT7 is developed by the AMA as a listing of descriptive terms and five-character identifying codes and modifiers for reporting medical services and procedures. The responsibility for the content of the Schedule of Medical and Hospital Fees is with the State of Oklahoma Workers’ Compensation Court and no endorsement by the AMA is intended or should be implied. The AMA disclaims any responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in the Schedule of Medical and Hospital Fees. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT7, and the AMA is not recommending their 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 CPT7 outside the Schedule of Medical and Hospital Fees should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT7 codes and descriptive terms. Applicable FARS/DFARS apply. CPT7 is a registered trademark of the American Medical Association. Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
Table of Contents Foreword ........................................................................................................................ 1 Introduction ..................................................................................................................... 1 General Ground Rules .................................................................................................... 5 Evaluation and Management ......................................................................................... 15 Anesthesia .................................................................................................................... 19 Surgery .......................................................................................................................... 27 Radiology ...................................................................................................................... 95 Pathology .................................................................................................................... 107 Medicine ...................................................................................................................... 125 Physical Medicine ....................................................................................................... 139 Dental Services ........................................................................................................... 145 Durable Medical Equipment, Supplies, Orthotics and Prostheses .............................. 147 Ambulance Services .................................................................................................... 149 Pharmaceutical Services ............................................................................................. 151 Ambulatory Surgical Center Services .......................................................................... 155 Inpatient Hospital Services .......................................................................................... 157 Inpatient Rehabilitation Facility Services ..................................................................... 181 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
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FOREWORD The Schedule of Medical and Hospital Fees outlines maximum reimbursement levels for health care providers, including hospitals and ambulatory surgical centers, rendering health care services to injured employees as provided in the Workers' Compensation Code, 85 O.S., Section 301 et seq. It applies to all health care services rendered after December 31, 2011 to employees with compensable injuries, regardless of the employee's date of injury. The Schedule of Medical and Hospital Fees does not apply to: (1) health care services performed under a certified workplace medical plan provided for in 85 O.S., Section 328; (2) health care services performed under a written contract between a health care provider and an employer or insurance carrier entered into pursuant to 85 O.S., Section 327(E); (3) health care services for which voluntary payments in excess of the reimbursement levels of the Schedule are made by a self-insured employer or an insurance carrier; or (4) disability evaluations provided as medical-legal evidence and performed by independent medical examiners appointed by the Workers= Compensation Court as provided in the Workers’ Compensation Code. Reimbursement of Court-appointed independent medical examiners is governed by Workers= Compensation Court Rule 44. This Schedule was adopted on December 22, 2011 as provided in 85 O.S., Section 327. The Schedule of Medical Fees is based on the most current Relative Value Units (RVU) produced by the Centers for Medicare and Medicaid Services (CMS) for the Medicare Physician Fee Schedule. The inpatient hospital services portion of the Schedule utilizes the Medical Severity Diagnosis Related Groups (MS-DRG) system as the primary coding system for health care services rendered. The inpatient rehabilitation facility services portion of the Schedule utilizes the Case-Mix Groups (CMG) system as a coding system for health care services rendered. The Schedule also adopts by reference the Centers for Medicare and Medicaid Services, CMS Healthcare Common Procedures Coding System (HCPCS) for the coding of certain supplies and materials, and for ambulance services. INTRODUCTION 1. PROCEDURE CODES: For purposes of the Schedule of Medical Fees, health care services and procedures shall be described in accordance with current procedural terminology codes and descriptions listed in the Physicians' Current Procedural Terminology, (CPT7), copyright 2010 by the American Medical Association. The accompanying instructions and ground rules of the Schedule of Medical Fees explain the application of these procedure descriptors and values in medical practice. All matters not specifically governed by the provisions of the Schedule of Medical Fees shall be subject to the provisions of CPT7 2011. If the provisions of the Schedule of Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
Medical Fees conflict with the provisions of CPT7 2011, the provisions of the Schedule of Medical Fees shall govern. The five character codes included in the Schedule of Medical Fees are obtained from Current Procedural Terminology, (CPT7), copyright 2010 by the American Medical Association (AMA). CPT7 is developed by the AMA as a listing of descriptive terms and five-character identifying codes and modifiers for reporting medical services and procedures. The responsibility for the content of the Schedule of Medical and Hospital Fees is with the State of Oklahoma Workers= Compensation Court and no endorsement by the AMA is intended or should be implied. The AMA disclaims any responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in the Schedule of Medical and Hospital Fees. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT7, and the AMA is not recommending their 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 CPT7 outside the Schedule of Medical and Hospital Fees should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT7 codes and descriptive terms. Applicable FARS/DFARS apply. CPT7 is a registered trademark of the American Medical Association. Allowables found in the right hand column of the Schedule of Medical and Hospital Fees were developed by the Administrator of the Oklahoma Workers' Compensation Court pursuant to 85 O.S., Section 327. 2. FORMAT: The Oklahoma Schedule of Medical and Hospital Fees consists of fourteen sections: Evaluation and Management; Anesthesia; Surgery; Radiology; Pathology; Medicine; Physical Medicine; Dental Services; Durable Medical Equipment, Supplies, Orthotics and Prostheses; Ambulance Services; Pharmaceutical Services; Ambulatory Surgical Center Services; Inpatient Hospital Services; and Inpatient Rehabilitation Facility Services. The Schedule is divided into these sections for structural purposes only. Providers of medical services and/or suppliers are to use the section(s) which contain the procedures they perform, or the services they render. 3. GROUND RULES: Introductory material, known as Ground Rules, follows the Introduction and precedes the separate sections of this Schedule. The Ground Rules contain the necessary general information, instructions, and general rules with which the user needs to become acquainted before undertaking the use of this Schedule. Familiarity with these general rules, which may include definitions, references, prohibitions, and directions for proper use, is necessary for all who use this Schedule. It cannot be emphasized too strongly that these rules need to be read before this Schedule is used. Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
4. HOW TO INTERPRET THE FEE SCHEDULE DATA: Each section of the Schedule is divided into columns. The columns vary by section. Following is a description of the various columns: a. CPT7 CODE (CURRENT PROCEDURAL TERMINOLOGY CODE): The CPT7 Code column lists the American Medical Association=s (AMA) CPT7 code. CPT7 2011 is used by arrangement with the AMA. b. MS-DRG CODE (MEDICAL SEVERITY DIAGNOSIS RELATED GROUPS CODE): The MS-DRG column lists the Centers for Medicare and Medicaid Services (CMS) Medical Severity Diagnosis Related Groups code as updated through September 6, 2011. c. CMG CODE (CASE-MIX GROUPS CODE): The CMG column lists the Centers for Medicare and Medicaid Services (CMS) Case-Mix Groups code as updated through October 1, 2011. d. ANES (ANESTHESIA): The ANES column shows base units for anesthesia services provided. These units are used for reimbursement when an anesthesiologist, or a non-physician anesthesia provider certified registered nurse anesthetist (CRNA) or anesthesiologist assistant (AA) rendering services within the scope of state licensure, provides anesthesia during a surgical procedure and bills using a surgical CPT7 code or when the operating surgeon provides regional or general anesthesia for surgery. e. FUD (FOLLOW-UP DAYS): The FUD column lists the number of follow-up days included in a surgical procedure=s global allowable. In counting follow-up days, day one is the day of surgery, not the discharge day. The follow-up days in this Schedule are derived from the Centers for Medicare and Medicaid Services (CMS). f. PC (PROFESSIONAL COMPONENT): The PC column shows the maximum allowable reimbursement amount for that portion of the procedure that is professional. The total maximum allowable reimbursed should never be more than the professional and technical components combined. In the Medicine Section, if there is no allowable noted in the PC column, the MAR listed is for the professional component only and there is no technical component for the code. g. TC (TECHNICAL COMPONENT): The TC column shows the maximum allowable reimbursement amount for that portion of the procedure that is technical. The total maximum allowable reimbursed should never be more than the professional and technical components combined. In the Medicine Section, if no allowable is noted in the PC column, the MAR listed is for the professional component only and there is no technical component for the code. Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
h. MAR (MAXIMUM ALLOWABLE REIMBURSEMENT): An MAR is listed for each code excluding Anesthesia codes, HCPCS codes, MS-DRG codes and CMG codes. The MAR column lists the maximum allowable reimbursement for a particular service or procedure performed under a CPT7 code. Dental services shall be reimbursed as provided in the Dental Services Ground Rules. Anesthesia codes shall be reimbursed as provided in the Anesthesia Ground Rules. HCPCS codes for supplies and materials shall be reimbursed as provided in the Durable Medical Equipment, Supplies, Orthotics and Prostheses Ground Rules. HCPCS codes for ambulance services shall be reimbursed as provided in the Ambulance Services Ground Rules. MS-DRG codes shall be reimbursed as provided in the Inpatient Hospital Services Ground Rules. CMG codes shall be reimbursed as provided in the Inpatient Rehabilitation Facility Services Ground Rules. i. BR (BY REPORT): Some services and procedures do not have a maximum allowable reimbursement amount because they are too variable or new. These Aby report@ services and procedures are identified with a ABR@. Reimbursement and billing for Aby report@ services and procedures are governed by the Aby report@ ground rule for the appropriate section. Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
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GENERAL GROUND RULES General Information and Instructions 1. REPRODUCTION OF MEDICAL RECORDS, INCLUDING X-RAYS AND OTHER PHOTOGRAPHS AND IMAGES, AND PATHOLOGY SLIDES: Under the provisions of 76 O.S., Section 19, providers (physicians, hospitals, medical professionals and institutions) may charge patients, former patients or the legal representative, spouse or responsible family member of any such person not more than One Dollar ($1.00) for the first page and fifty cents ($0.50) for each subsequent page for copies of medical records other than any x-ray or other photograph or image or pathology slide. Reproduction of the record in digital form may be provided at a cost not to exceed twelve cents ($0.12) per digital page. The cost of each x-ray, other photograph or image, or pathology slide shall not exceed Five Dollars ($5.00) or the actual cost of reproduction, whichever is less. Medical providers may charge a patient for the actual cost of mailing the patient=s requested medical records, but may not charge an additional fee for searching, retrieving, reviewing or preparing such records for copying, or for providing copies by facsimile. Taxes, including sales taxes, are not reimbursable costs for reproduction of medical records. 2. MEDICAL TESTIMONY, INCLUDING DEPOSITIONS: a. REIMBURSEMENT: Reimbursement for medical testimony given in person or by deposition shall be in accordance with the physician=s usual and customary charges, not to exceed Four Hundred Dollars ($400.00) per hour or any portion thereof, plus an allowance of One Hundred Dollars ($100.00) for 15 minute increments thereafter. b. PREPARATION TIME: Preparation time for medical testimony, including depositions, shall be reimbursed at the examiner=s usual and customary charge, not to exceed Four Hundred Dollars ($400.00). c. CANCELLATION FEE: A Four Hundred Dollar ($400.00) charge is allowable whenever a deposition or scheduled testimony is canceled by the employer or employee within three working days prior to the scheduled start of the deposition or scheduled testimony. d. ADVANCE PAYMENT: A physician may request not more than Two Hundred Dollars ($200.00) in advance in order to schedule a deposition. The advance payment shall be applied against amounts owed for testimony fees. e. BILLING: All bills submitted for payment shall be itemized, including the number of hours required to perform the services, and shall refer to this Ground Rule and CPT7 Code 99075 for proper reimbursement. Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
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This ground rule does not apply to reimbursement of a Court-appointed independent medical examiner for medical testimony given in person or by deposition. Reimbursement of Court-appointed independent medical examiners is governed by Workers= Compensation Court Rule 44. 3. DIAGNOSTIC TESTS: Pursuant to Title 85 O.S., Section 326, diagnostic tests shall not be repeated sooner than six (6) months from the date of the test unless agreed to by the parties or ordered by the Workers’ Compensation Court. 4. REPORT PREPARATION, BILLING AND MAXIMUM ALLOWANCE: a. Routine reports: Completion of routine reports or records is incorporated in all fees for service and is not reported separately. Routine reports include reports of diagnostic testing, procedure reports, progress notes, office notes, operative reports and return to work forms. Requests for additional copies of routine reports are reimbursable at the copying fee rates provided for in General Ground Rule 1. b. Physician’s Report on Treatment of Workers’ Compensation Injury: Effective August 26, 2011, Oklahoma law no longer requires a worker’s treating physician to produce an initial report of the worker’s injuries found at the time of examination and proposed treatment, or to produce a final report of treatment at the conclusion of treatment. However, if either report is prepared, reimbursement and billing is subject to this ground rule. (1) Initial Report: If prepared, the maximum allowance for completion and submission of the initial report to the injured worker and the worker’s employer is $36.00. “F4-010” should be used as the billing code. Workers’ Compensation Court Form 4 (Treating Physician’s Report and Notice of Treatment) is recommended for use in the event an initial report is prepared. (2) Final Report: If prepared, the maximum allowance for completion and submission of the final report to the worker’s employer is $36.00. “F4-020” should be used as the billing code. c. Permanent Impairment Rating Services: Work-related or medical disability examinations described in CPT7 code 99455 that are performed by the treating physician, at the request of a party, and work-related or medical disability examinations described in CPT7 code 99456 that are performed by a physician other than the treating physician, at the request of a party, shall be reimbursed as provided below. CPT7 codes 99455 and 99456 require, among other things, a calculation of impairment. (1) REIMBURSEMENT: The review of records and information, the performance of any necessary examinations, and the preparation of the Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
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written report shall be billed and reimbursed at the physician=s usual and customary rate, not to exceed Two Hundred Dollars ($200.00) per hour, up to a maximum of three (3) hours. In a complex case, an additional fee of up to Two Hundred Dollars ($200.00) may be allowed. (2) DIAGNOSTIC TESTS: Payment for any required diagnostic tests shall be in accordance with this Schedule of Medical and Hospital Fees. (3) CANCELLATION FEE: If an examination is canceled by the employee or the employer within forty-eight (48) hours of the scheduled time, a Two Hundred Dollar ($200.00) fee is allowable for the cancellation. (4) BILLING: All bills submitted for payment shall be itemized, including the number of hours required to perform the services, and shall refer to this Ground Rule and CPT7 code 99455 or 99456, as appropriate, for proper reimbursement. d. Narrative Reports: Party requested reports not otherwise addressed under this ground rule, including narrative reports involving the provider’s review of medical data to clarify a patient=s status or requesting more than the information conveyed in the usual medical communications or standard reporting form are special reports that may be billed using CPT7 code 99080. Except as otherwise agreed upon by the provider and requesting party, following is the maximum allowance for a special report: First page ................................. $36.00 Each additional page ............... $14.00 Not to exceed........................... $64.00 e. General Ground Rule 4 does not apply to: (1) reports and services, including impairment evaluations, performed by an independent medical examiner appointed by the Workers= Compensation Court. Reimbursement of Court-appointed independent medical examiners is governed by Workers= Compensation Court Rule 44; or (2) health care services (including work-related or medical disability services) performed under a written contract between a health care provider and an employer or insurance carrier entered into pursuant to 85 O.S., Section 327(E). 5. BILLING PROCEDURES: If a charge is billed using a procedure code not found in this fee schedule, but found in the Physicians' Current Procedural Terminology, by the American Medical Association (CPT7) book, reimbursement should be made. Relativity should be maintained by using a fee schedule code and value as a reference. Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
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Medical providers may not bill more than their usual and customary charge for any procedure. If a medical provider's total aggregate charges per billing do not exceed the total aggregate allowed by the fee schedule for such charges, after application of all appropriate ground rules and other instructions per the fee schedule, then the medical provider=s total aggregate charges should be reimbursed in full. For example, CPT7 Provider=s Maximum Allowable Code Charges Per Fee Schedule 99203 $75.00 $146.61 95860-26 $100.00 $87.42 $175.00 $234.03 The provider should be paid $175.00 since the total billed charges are less than the total allowable per the fee schedule. This ground rule does not apply to ambulatory surgical center services, inpatient hospital services, inpatient rehabilitation facility services, or implantables. 6. MODIFIERS: Modifiers augment CPT7 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, alpha, or alpha-numeric combination placed after the usual procedure code, separated by a hyphen. If more than one modifier is needed, place the multiple modifiers code (-99) after the procedure code to indicate that two or more modifiers will follow. 7. EXPLANATION OF BENEFITS: A payer must provide a health care provider with a written explanation of benefits (EOB) whenever a coded service is denied or not reimbursed in full as billed. The EOB must identify each coded service that was denied or not reimbursed in full as billed; the amount reimbursed, if applicable; the reason for each denial or reduced reimbursement (including the citing of the specific general instruction, ground rule, or other provision of the Schedule of Medical and Hospital Fees serving as the basis for the denial or reduction); and the procedure code, if any, for which reimbursement was made when different from the code billed. If the reason for a denial or reduced reimbursement is reliance upon usual and customary charge or reimbursement data, the EOB also must disclose the usual and customary data serving as the basis for each denial or reduction. “Usual and Customary Charge” as defined in the Schedule of Medical and Hospital Fees refers to the usual fee charged by the provider to all patients for the same or substantially similar services under like circumstances. Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
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8. DISPUTES REGARDING PAYMENT FOR HEALTH CARE SERVICES: Disputes regarding payment for health care services rendered as provided in the Workers' Compensation Code may be addressed using informal dispute resolution procedures available through the Workers' Compensation Court. The procedures include the Form 18 and Form 19 processes, and mediation. A description of each follows. a. FORM 18 (COURT ADMINISTRATOR REVIEW OF DISPUTED CHARGES INVOLVING CONFLICTING INTERPRETATIONS OF THE WORKERS’ COMPENSATION FEE SCHEDULE): Workers' Compensation Court Rule 50 governs the review of payment disputes involving conflicting interpretations of the Schedule of Medical and Hospital Fees. A request for review of such disputed medical charges under Rule 50 may be made by the filing of a Form 18, Request for Court Administrator Review of Medical Charges. The Administrator may review the disputed charges only to determine if the entire bill submitted is reimbursed appropriately under the Schedule of Medical and Hospital Fees. The Administrator may not determine if the treatment rendered was necessary, nor may the Administrator resolve other matters requiring a judicial determination for resolution. If either party is aggrieved by the Administrator's order, an appeal of the decision may be made to a trial judge of the Workers' Compensation Court by filing a Form 9 (Motion to Set for Trial) and a Form 19, Part II., Notice of Appeal of Court Administrator Order. The appeal must be filed within ten (10) days of the file-stamped date of the Administrator=s order. b. FORM 19 (MAY INVOLVE JUDICIAL RESOLUTION OF DISPUTED CHARGES): Court Rule 50 governs the process for health care providers seeking to recover charges for health care services, medicines or supplies provided to an injured employee. Health care providers may file a Form 19, Part I., Request For Payment Of Charges For Health Or Rehabilitation Services, if they have not received payment within 45 days of receipt by the employer or insurance carrier of a complete and accurate invoice, or if the employer or insurance carrier denies liability on a ground requiring judicial resolution. Such grounds include: (1) length of treatment; (2) necessity of treatment; (3) unauthorized physician; (4) denial of compensability of the claimant's claim; and (5) any other issues requiring a judicial determination. The Workers= Compensation Court will not set the Form 19 for hearing unless a Form 9 (Motion to Set for Trial) also is filed. c. MEDIATION: Mediation may be used to address certain workers= compensation disputes (including disputes regarding payment for medical and rehabilitative services). Mediation is the process of resolving disputes with the assistance of a mediator, outside of a formal court proceeding. The purpose of mediation is to identify issues, clarify misunderstandings, explore solutions, and negotiate settlement. It is an alternative to litigation. For information, call (405) 522-8760 or in-state toll free at (800) 522-8210. See also, 85 O.S., Section 321 and Court Rule 52 and Court Rule 53, available on the Workers’ Compensation Court’s website at http://www.owcc.state.ok.us. Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
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Failure of an employer or insurance carrier to pay medical charges within the forty-five (45) day period as required by the Workers= Compensation Code, may result in a penalty, payable to the provider, of up to twenty-five percent (25%) of any amount due under the Schedule of Medical and Hospital Fees that remains unpaid. Under 85 O.S., Section 327(K), if the Court finds a pattern of willful and knowing delay of payments, it may assess a penalty of not more than Five Thousand Dollars ($5,000.00) per occurrence, payable as directed by the Court. Under 85 O.S., Section 327(D), the right to recover charges for every type of medical care for compensable workers= compensation injuries lies solely with the Oklahoma Workers= Compensation Court. Additional information about resolving payment disputes may be obtained from the Workers' Compensation Court, 1915 North Stiles Avenue, Oklahoma City, Oklahoma 73105, (405) 522-8794. 9. MEDICAL TREATMENT GUIDELINES: a. (1) OFFICIAL DISABILITY GUIDELINES AND OKLAHOMA TREATMENT GUIDELINES: Effective March 1, 2012, the scope and duration of medical treatment shall be governed by the Work Loss Data Institute’s “Official Disability Guidelines” (ODG). ODG may be ordered by calling 800-488-5548 or going to http://worklossdata.com/. Medical care not addressed by the ODG or addressed but not recommended in the ODG section for injuries to the cervical, thoracic or lumbar spine, or for pain management or continuing medical maintenance, shall be governed by Oklahoma Treatment Guidelines (OTG) recommended by the Physician Advisory Committee and adopted as provided in 85 O.S., Section 373. (2) REQUIRED USE: Compliance with treatment guidelines applicable by law or adopted as provided in Title 85 of the Oklahoma Statutes shall be mandatory and an employer or insurer for an employer shall not be required to pay for treatment which is not in compliance with the guidelines, unless the medical treatment was provided in a medical emergency, the medical treatment was preauthorized by the employer or insurance carrier, or the medical treatment is approved by the Workers’ Compensation Court based on a determination that medical treatment according to either the ODG or OTG is not in the best interest of the employee. When an accidental injury or occupational disease falls within the purview of the treatment guidelines, providers shall use the appropriate medical treatment guidelines then in effect to care for and treat the injured worker. Providers are expected to stay current with guideline changes and adoptions. If the treatment guidelines conflict with ground rules in the Schedule of Medical and Hospital Fees, the treatment guidelines shall govern. Pursuant to 85 O.S., Section 328(D), Certified Workplace Medical Plans may use medical treatment Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
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guidelines and protocols substantially similar to those recommended by the Physician Advisory Committee and adopted as provided in 85 O.S., Section 373. b. PURPOSE AND APPLICATION OF GUIDELINES: The objective of medical treatment guidelines is to provide standards for prompt, reasonable and appropriate treatment for workplace injuries and to expedite optimum recovery and return to work, while containing medical costs in the workers' compensation system. The guidelines do not affect any determination of liability for an injury under the Oklahoma Workers' Compensation Code, 85 O.S., Section 301, et seq., and are not intended to expand or restrict a health care provider's scope of practice under any other statutes. c. STATUS OF OKLAHOMA TREATMENT GUIDELINES: For information on the status of Oklahoma Treatment Guidelines, call the Workers’ Compensation Court at (405) 522-8794 or in-state toll free at (800) 522-8210, or check the Court=s website at http://www.owcc.state.ok.us/guidelines.htm. 10. CASE MANAGEMENT: Pursuant to 85 O.S., Section 308(5), case management is the ongoing coordination by a case manager of health care services provided to an injured or disabled worker. It is a utilization control designed to promote the timely delivery of quality, cost-effective and medically appropriate health care services to an injured worker to assist the worker in reaching maximum medical improvement, and to promote prompt return to work as appropriate. Case management may be provided by agreement of the parties, by an insurer or certified workplace medical plan, or pursuant to a Court order for cases not covered by a certified workplace medical plan and where the employer, insurance carrier or own-risk employer does not provide case management. Court ordered case management may be granted on the request of a party, or when the Court determines that case management is appropriate. If case management is used, it should be governed by the Case Management Guidelines recommended by the Physician Advisory Committee (85 O.S., Section 373) and adopted as provided by law. The Guidelines are available on the Court=s website at http://www.owcc.state.ok.us. Case types or situations which may benefit most from case management services include: a. Catastrophic injuries including burns, amputations, crush injuries, head injuries, spinal cord injuries (SCI) and complex regional pain syndrome (RSD) cases; b. When noncompliance issues with the medical treatment plan have been identified; c. When multiple medical providers or frequent changes in physician have occurred; Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
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d. When problems with certain issues would be more appropriately evaluated in person, which may include, but are not limited to, language barriers, transportation obstacles and socio-economic dynamics; e. In the event of re-injury to the same body part; f. When the injured worker, physician, payer, employer or attorney request medical case management; g. When the treatment plan exceeds usual and customary parameters as set forth by law or applicable medical treatment guidelines adopted as provided by law; h. In cases where pre-existing medical conditions could impact the extent or duration of rehabilitation; i. Compromised communication; j. When assistance is needed with return-to-work issues. 11. EMERGENCY ROOM SERVICES: The purpose of this ground rule is to clarify reimbursement of emergency room facility fees. All facility bills for an emergency room encounter involving no surgery in the emergency room shall be paid at 60% of amounts charged for services documented as rendered during the emergency room encounter and which are related to the work-related injury; provided, charges for radiology, pathology and laboratory, and durable medical equipment and supplies, must be billed separately and are subject to the professional services fee schedule, or durable medical equipment ground rules, as applicable. All facility bills for an emergency room encounter involving surgical procedures in the emergency room and all related charges are reimbursed pursuant to the Ambulatory Surgical Center Ground Rules. 12. IMPLANTABLE MEDICAL DEVICES: a. For purposes of this ground rule, “implantables” means those services indicated by revenue codes 274 (prosthetic/orthotic devices), 275 (pace maker), 276 (intraocular lens), and 278 (other implants), which involve an item or device intended for permanent placement in the body. "Implantable items" include rods, pins, screws, plates, prosthetic joint replacements, and other items properly indicated by revenue code 278 which are made of plastic, metallic, or of autogenous/non-autogenous graft material. b. Any entity which buys and resells implantable devices to a hospital, ambulatory surgical center or physician shall be limited to a markup of ten percent (10%) above the manufacturer’s invoice price for that implantable device, adjusted to reflect all applicable discounts, rebates, considerations and product replacement programs. Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
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13. PHYSICIAN ASSISTANT AND REGISTERED NURSE FIRST ASSISTANT SERVICES: a. EVALUATION AND MANAGEMENT SERVICES: A certified physician assistant shall be allowed eighty-five percent (85%) of the fee schedule allowance for evaluation and management services provided a signed report details the findings of the examination and the CPT7 code level billed is supported by the signed report. b. ASSISTANT TO SURGEON (IN LIEU OF ASSISTANT SURGEON): A certified physician assistant or registered nurse first assistant, minimum assistant surgeon used as a surgical assistant shall be reimbursed at ten percent (10%) of the fee schedule allowance for the procedure(s). The CPT7 codes billed must coincide with those of the surgeon. Physician assistant or registered nurse first assistant fees are not payable when qualified hospital staff or ambulatory surgical center staff is provided to assist at surgery. An assistant surgeon, and certified physician assistant or registered nurse first assistant, cannot both be present or their services billed on the same surgical case. c. OTHER SERVICES: A physician assistant shall be allowed eighty-five percent (85%) of the fee schedule allowance for any other services performed within the physician assistant’s license and certification. d. MODIFIERS: When billing for services provided by a physician assistant, use the modifier “-PA”. When billing for services provided by a registered nurse first assistant, use modifier “-FA”. 14. NO-SHOW FEE FOR MISSED APPOINTMENTS: If an injured worker fails to appear for a scheduled appointment with a physician, a Two Hundred Dollar ($200.00) fee, to be paid initially by the employer or insurance carrier, is allowable for the failure to appear. The respondent shall be reimbursed by the injured worker if the failure to appear was determined by the Court to be without good cause. For purposes of this ground rule, “physician” means a treating physician, and a physician performing permanent impairment rating services described in General Ground Rule 4(c), but excludes a Court appointed independent medical examiner whose fees are governed by Workers’ Compensation Court Rule 44. Bills submitted for payment of the no-show fee shall refer to this ground rule and CPT7 code 99499 with the modifier “-NS”. 15. REQUIRED DISCLOSURES: a. Pursuant to 85 O.S., Section 327(J), if a physician or an entity in which the physician has a financial interest, other than an ownership interest of less than five percent (5%) in a publicly traded company, provides implantable devices, that relationship must be disclosed to the patient, employer, insurance company, third party administrator, certified workplace medical plan, case manager, and legal counsel for the worker and employer/carrier. Workers’ Compensation Court Form 17 may be used for this purpose. Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
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b. Pursuant to 85 O.S., Section 327(M), physicians providing treatment under the Workers’ Compensation Code shall disclose on the Workers’ Compensation Court Form 17 any ownership interest in a healthcare facility, business or diagnostic center that is not the physician’s primary place of business, including any employee leasing arrangement between the physician and any healthcare facility that is not the physician’s primary place of business. Failure to do so is grounds for the Workers’ Compensation Court Administrator to disqualify the physician from providing treatment under the Workers’ Compensation Code. c. The Workers’ Compensation Court Form 17 is available on the Court’s web site at http://www.owcc.state.ok.us/court_forms.htm. Signed and completed Form 17s shall be filed with the Workers’ Compensation Court Administrator, 1915 N. Stiles Avenue, Oklahoma City, OK 73105, and may be subject to inspection and copying by the general public. Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
Evaluation and Management
Ground Rules
EVALUATION AND MANAGEMENT GROUND RULES General Information and Instructions 1. GENERAL: Visits, examinations, consultations, and similar services as listed in this section reflect the wide variations in time and skill required in the diagnosis and treatment of illness or injury. Documentation for each aspect of the service performed should be included in the patient record to substantiate the level of service. The listed values for each code group apply only when these services are performed by or under the responsible supervision of a physician. 2. BY REPORT ("BR") ITEMS: "BR" in the maximum allowable reimbursement (MAR) column indicates that the value of this service is to be determined "by report", because the service is too unusual or variable to be assigned a value. For any "by report" code, medical providers should identify a similar service and justify the difference between their charge and the value of the referenced service. Pertinent information concerning the nature, extent and need for the procedure or service, the time, the skill and equipment necessary, etc. is to be furnished. A detailed clinical record is not necessary. 3. CONCURRENT CARE: When more than one physician treats a patient for the same condition during the same period of time, payment is made only to one physician; the one whose specialty is most relevant to the diagnosis. When the condition of the patient requires the distinct and separate skills of two or more physicians to treat different conditions which do not fall within the scope of other physicians treating the patient at the same time, payment is due each physician who plays an active role in the treatment program. The services rendered by each physician shall be distinct, in different disciplines, identifiable and adequately documented in the records and reports. 4. ALTERNATING PHYSICIANS: When physicians of similar skills alternate in the care of a patient, (e.g., partners, groups or same facility; covering for another physician on weekends or vacation periods) each physician shall bill individually for the services each personally rendered. 5. CONSULTATIONS AND REFERRALS: A consultation is a service rendered by a specialist at the request of the treating physician or other appropriate source seeking further evaluation and/or an opinion on how to proceed in the management of a patient's illness. Consultations always require a narrative report from the consultant to the treating physician requesting the opinion. A detailed narrative report is required and shall accompany the bill. A reproduction of a form report is not acceptable since the particulars relevant to one individual will not be applicable to another patient. When the consulting specialist assumes responsibility for the continuing care of the patient, any subsequent service rendered by him/her will cease to be a consultation. Subsequent care will be reimbursed according to the actual level of service rendered. Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
Evaluation and Management
Ground Rules
A referral is the transfer of a patient to a specialist for diagnosis and, where necessary, treatment of a specific illness or injury, rather than for advice. A referral will be reimbursed according to the actual level of services rendered. 6. NEW PATIENT: ”New patient” means a patient who is new to the health care provider, group practice, or caregiver and/or whose medical and administrative records need to be established. A patient shall also be considered a new patient if seen for a new injury or disability or when a lapse of three or more years from the most recent prior visit has occurred. 7. ESTABLISHED PATIENT: An established patient is one who has received professional services from the physician within the last three years or whose medical and administrative records are available to the physician. In the instance where a physician is covering for or on call for another physician, the patient’s encounter will be classified as it would have been by the physician who is not available. 8. SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE DAY OF A PROCEDURE: Evaluation and Management services above and beyond normal preoperative and postoperative care associated with a procedure and performed on the same day may be reimbursed. Services of this nature must be substantiated by report. Use modifier -25 to indicate this type of service. 9. DURABLE MEDICAL EQUIPMENT AND SUPPLIES PROVIDED BY PHYSICIAN: Durable medical equipment and supplies provided by the physician over and above those usually included with the office visit or other services rendered are governed by the Durable Medical Equipment, Supplies, Orthotics and Prostheses Ground Rules. 10. UNLISTED SERVICES OR PROCEDURES: A service or procedure that is not identified by a particular CPT7 code should be listed under the appropriate AUnlisted Procedure@. These procedures often have A99" as the final two digits. Values should be substantiated Aby report@. 11. LEVELS AND COMPONENTS OF SERVICE: Reference should be made to the Physicians' Current Procedural Terminology, (CPT7 2011), copyright 2010 by the American Medical Association for information on Levels of Service and Components of Service. Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Evaluation and Management
CPT Code MAR 99201 $58.43 99202 $101.28 99203 $146.61 99204 $226.20 99205 $282.29 99211 $27.95 99212 $58.91 99213 $98.60 99214 $146.48 99215 $197.36 99217 $100.10 99218 $93.02 99219 $155.43 99220 $217.34 99221 $139.92 99222 $190.62 99223 $280.34 99224 $40.23 99225 $71.43 99226 $106.83 99231 $55.56 99232 $100.50 99233 $144.30 99234 $189.50 99235 $249.21 99236 $309.71 99238 $99.75 99239 $146.42 99241 $62.92 99242 $118.48 99243 $163.07 99244 $243.06 99245 $299.00 99251 $65.67 99252 $101.59 99253 $154.12 99254 $222.90 99255 $271.59 99281 $30.11 99282 $58.58 99283 $88.73 99284 $167.28 99285 $245.51 99288 BR 99291 $379.86 CPT Code MAR 99292 $171.38 99304 $126.63 99305 $178.10 99306 $227.13 99307 $60.89 99308 $93.65 99309 $123.30 99310 $182.67 99315 $88.80 99316 $115.56 99318 $130.26 99324 $79.38 99325 $114.90 99326 $195.26 99327 $256.62 99328 $300.27 99334 $84.33 99335 $130.77 99336 $184.49 99337 $265.44 99339 BR 99340 BR 99341 $78.90 99342 $114.77 99343 $187.53 99344 $252.06 99345 $302.85 99347 $78.41 99348 $118.83 99349 $175.98 99350 $245.09 99354 $137.91 99355 $136.49 99356 $126.35 99357 $126.81 99358 BR 99359 BR 99360 BR 99363 BR 99364 BR 99366 BR 99367 BR 99368 BR 99374 $102.02 99375 BR CPT Code MAR 99377 $102.02 99378 BR 99379 $101.83 99380 $137.89 99381 $154.45 99391 $117.12 99441 BR 99442 BR 99443 BR 99444 BR 99450 BR 99455 SEE GEN GR 4 99456 SEE GEN GR 4 99460 $84.02 99461 $130.26 99462 $45.26 99463 $114.62 99464 $104.36 99465 $200.79 99466 $372.54 99467 $171.99 99468 $1,298.46 99469 $568.50 99471 $1,124.79 99472 $565.35 99475 $791.75 99476 $479.43 99477 $501.56 99478 $198.75 99479 $182.49 99480 $170.31 99499 BR Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
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Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
Anesthesia
Ground Rules
ANESTHESIA GROUND RULES General Information and Instructions 1. GENERAL: a. The maximum allowable reimbursement for anesthesia services administered by an anesthesiologist shall be in an amount calculated per these Ground Rules. The maximum allowable reimbursement for anesthesia services administered by a non-physician anesthesia provider certified registered nurse anesthetist (CRNA) or anesthesiologist assistant (AA) rendering services within the scope of state licensure shall not exceed ninety percent (90%) of that amount. b. A base allowable is listed for each anesthesia code. These allowables are to be used only when the anesthesia is personally administered by an anesthesiologist, CRNA or AA who remains in constant attendance during the procedure, for the sole purpose of rendering such anesthesia service. These allowables include preoperative and postoperative visits, the administration of the anesthetic and the administration of fluids and/or blood incident to anesthesia or surgery. c. The anesthesia allowable includes recovery room care. No additional time units are allowed for recovery room observation and monitoring. 2. BILLING: Billing for anesthesia services will include, but not be limited to the procedure code number, time units, amount of charges, provider information and any other information that pertains to the amount charged. 3. UNLISTED SERVICES OR PROCEDURES: A service or procedure that is not identified by a particular CPT7 code should be listed under the appropriate AUnlisted Procedure@. These procedures often have A99" as the final two digits. Values should be substantiated Aby report@. 4. BY REPORT (ABR@) ITEMS: "BR" in the base allowable column indicates that the value of this service is to be determined "by report". For any "by report" code, medical providers should identify a similar service and justify the difference between their charge and the value of the referenced service. Pertinent information concerning the nature, extent and need for the procedure or service, the time, the skill and equipment necessary, etc. is to be furnished. A detailed clinical record is not necessary. 5. DURABLE MEDICAL EQUIPMENT AND SUPPLIES PROVIDED BY PHYSICIAN: Durable medical equipment and supplies provided by the physician over and above those usually included with the office visit or other services rendered are governed by the Durable Medical Equipment, Supplies, Orthotics and Prostheses Ground Rules. Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
Anesthesia
Ground Rules
6. SUPPLEMENTAL SKILLS: When warranted by the necessity of supplemental skills, reimbursement for the services of two or more physicians and/or anesthetists will be allowed. Substantiate by report justifying the need. 7. MONITORING SERVICES: When an anesthesiologist, CRNA or AA is required to participate in and be responsible for monitoring the general care of the patient during a surgical procedure but does not administer anesthesia, these services are charged on the basis of the extent of the services rendered. Payment will be made on the basis of the time units the anesthesiologist, CRNA or AA is in constant attendance for the sole purpose of the monitoring services. Anesthesia values will not be added. 8. ANESTHESIA ADMINISTERED BY OTHER THAN AN ANESTHESIOLOGIST, CRNA OR AA: Anesthesia fees are not payable when local infiltration, digital block or topical anesthesia is administered by the operating surgeon or surgical assistants. Such services are included in the value for the surgical procedure. 9. ANESTHESIA PHYSICAL STATUS MODIFIERS: The following physical status modifiers are consistent with the American Society of Anesthesiologists= ranking of patient physical status, and distinguish various levels of complexity of the anesthesia service provided. All anesthesia services are reported by use of the anesthesia five-digit procedure code (00100 - 01999) with the appropriate physical status modifier appended. Under certain circumstances, when another established modifier(s) is appropriate, it should be used in addition to the physical status modifier. Physical Status Modifiers: Physical Status modifiers are represented by the initial letter AP@ followed by a single digit from 1 to 6 defined below: Physical Status Modifier Allowable P1 -- A normal healthy patient. $0.00 P2 -- A patient with mild systemic disease. $0.00 P3 -- A patient with severe systemic disease. $46.58 P4 -- A patient with severe systemic disease that is a constant threat to life.$93.16 P5 -- A moribund patient who is not expected to survive without the operation. $139.74 P6 -- A declared brain-dead patient whose organs are being removed for donor purposes. $0.00 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
Anesthesia
Ground Rules
10. QUALIFYING CIRCUMSTANCES: More than one qualifying circumstance may be selected. Many anesthesia services are provided under particularly difficult circumstances, depending on factors such as extraordinary condition of patient, notable operative conditions, and/or unusual risk factors. This ground rule includes a list of important qualifying circumstances that significantly impact on the character of the anesthesia service provided. These procedures would not be reported alone but would be reported as additional procedure numbers qualifying an anesthesia procedure or service. CPT7 Code Allowable 99100 $46.58 99116 $232.90 99135 $232.90 99140 $93.16 An emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part. 11. MONITORING EQUIPMENT: When a pulse oximeter monitor and a capnography monitor are not provided by the hospital and are owned and operated by the anesthesiologist during general anesthesia exceeding 30 minutes, $46.58 per monitor may be charged. 12. CALCULATIONS OF TOTAL ANESTHESIA ALLOWABLES: The total Anesthesia allowable is calculated by adding the following: a. The Anesthesia Base Allowable listed for the service provided; b. The Allowable for the Physical Status Modifier; c. The Allowable for Qualifying Circumstances, if appropriate; d. The Allowable for Monitoring Equipment, if appropriate; and e. The Allowable for time units. Time units are computed by allowing one unit for each 15 minutes or significant fraction thereof of anesthesia time. Anesthesia time begins when the anesthesiologist, CRNA or AA starts physically to prepare the patient for the induction of anesthesia in the operating room area (or in an equivalent area) and ends not more than 15 minutes after service in the operating room is concluded and the patient is placed under postoperative supervision. If the anesthesia time extends beyond two hours, 1.0 unit for each 10 minutes or significant fraction thereof is allowed after the first two hours. This does not apply to Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
Anesthesia
Ground Rules
obstetrical anesthesia for which 15 minute time increments are applicable for the entire duration of the service. The total time units are multiplied by $46.58 to determine the allowable for time units. Actual time of beginning and duration of anesthesia time may require documentation, such as a copy of the anesthesia record in the hospital file. This documentation is not required to be provided unless a dispute arises between the payer and anesthesia provider regarding the anesthesia time. Fees when applicable are identical for general, spinal, regional or refrigeration anesthesia. When multiple surgical procedures are performed during the same period of anesthesia, only the greatest allowable of the various surgical procedures will be used. To this allowable are added time units applicable for the entire period of anesthesia time for the multiple procedures performed. 13. MISCELLANEOUS: a. For cardiopulmonary resuscitation (separate procedure unrelated to the administration of anesthesia) see CPT7 code 92950. b. Values for office and hospital visits, consultations and other medical services, x-rays, surgery, and laboratory procedures are listed in the sections entitled AEvaluation and Management@, AMedicine@, ASurgery@, ARadiology@, and APathology@. A consultation fee is not payable to an anesthesiologist, CRNA or AA examining the patient before administering anesthesia to that patient. No additional charge is to be made for routine follow-up care and observation. Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Anesthesia
CPT Code MAR 00100 $232.90 00102 $279.48 00103 $232.90 00104 $186.32 00120 $232.90 00124 $186.32 00126 $186.32 00140 $232.90 00142 $186.32 00144 $279.48 00145 $279.48 00147 $186.32 00148 $186.32 00160 $232.90 00162 $326.06 00164 $186.32 00170 $232.90 00172 $279.48 00174 $279.48 00176 $326.06 00190 $232.90 00192 $326.06 00210 $512.38 00211 $465.80 00212 $232.90 00214 $419.22 00215 $419.22 00216 $698.70 00218 $605.54 00220 $465.80 00222 $279.48 00300 $232.90 00320 $279.48 00322 $139.74 00326 $326.06 00350 $465.80 00352 $232.90 00400 $139.74 00402 $232.90 00404 $232.90 00406 $605.54 00410 $186.32 00450 $232.90 CPTCode MAR 00452 $279.4800454 $139.7400470 $279.4800472 $465.8000474 $605.5400500 $698.7000520 $279.4800522 $186.3200524 $186.3200528 $372.6400529 $512.3800530 $186.3200532 $186.3200534 $326.0600537 $326.0600539 $838.4400540 $558.9600541 $698.7000542 $698.7000546 $698.7000548 $791.8600550 $465.8000560 $698.7000561 $1,164.5000562 $931.6000563 $1,164.5000566 $1,164.5000567 $838.4400580 $931.6000600 $465.8000604 $605.5400620 $465.8000622 $605.5400625 $605.5400626 $698.7000630 $372.6400632 $326.06
00634
$465.80
00635
$186.32
00640
$139.74
00670
$605.54
00700
$186.32
00702
$186.32CPT Code MAR
00730
$232.90
00740
$232.90
00750
$186.32
00752
$279.48
00754
$326.06
00756
$326.06
00770
$698.70
00790
$326.06
00792
$605.54
00794
$372.64
00796
$1,397.40
00797
$512.38
00800
$186.32
00802
$232.90
00810
$232.90
00820
$232.90
00830
$186.32
00832
$279.48
00834
$232.90
00836
$279.48
00840
$279.48
00842
$186.32
00844
$326.06
00846
$372.64
00848
$372.64
00851
$279.48
00860
$279.48
00862
$326.06
00864
$372.64
00865
$326.06
00866
$465.80
00868
$465.80
00870
$232.90
00872
$326.06
00873
$232.90
00880
$698.70
00882
$465.80
00902
$232.90
00904
$326.06
00906
$186.32
00908
$279.48
00910
$139.74
00912
$232.90Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Anesthesia
CPT Code MAR
00914
$232.90
00916
$232.90
00918
$232.90
00920
$139.74
00921
$139.74
00922
$279.48
00924
$186.32
00926
$186.32
00928
$279.48
00930
$186.32
00932
$186.32
00934
$279.48
00936
$372.64
00938
$186.32
00940
$139.74
00942
$186.32
00944
$279.48
00948
$186.32
00950
$232.90
00952
$186.32
01112
$232.90
01120
$279.48
01130
$139.74
01140
$698.70
01150
$465.80
01160
$186.32
01170
$372.64
01173
$558.96
01180
$139.74
01190
$186.32
01200
$186.32
01202
$186.32
01210
$279.48
01212
$465.80
01214
$372.64
01215
$465.80
01220
$186.32
01230
$279.48
01232
$232.90
01234
$372.64
01250
$186.32
01260
$139.74
01270
$372.64 CPTCode MAR
01272
$186.32
01274
$279.48
01320
$186.32
01340
$186.32
01360
$232.90
01380
$139.74
01382
$139.74
01390
$139.74
01392
$186.32
01400
$186.32
01402
$326.06
01404
$232.90
01420
$139.74
01430
$139.74
01432
$279.48
01440
$372.64
01442
$372.64
01444
$372.64
01462
$139.74
01464
$139.74
01470
$139.74
01472
$232.90
01474
$232.90
01480
$139.74
01482
$186.32
01484
$186.32
01486
$326.06
01490
$139.74
01500
$372.64
01502
$279.48
01520
$139.74
01522
$232.90
01610
$232.90
01620
$186.32
01622
$186.32
01630
$232.90
01632
$279.48
01634
$419.22
01636
$698.70
01638
$465.80
01650
$279.48
01652
$465.80
01654
$372.64CPT Code MAR
01656
$465.80
01670
$186.32
01680
$139.74
01682
$186.32
01710
$139.74
01712
$232.90
01714
$232.90
01716
$232.90
01730
$139.74
01732
$139.74
01740
$186.32
01742
$232.90
01744
$232.90
01756
$279.48
01758
$232.90
01760
$326.06
01770
$279.48
01772
$279.48
01780
$139.74
01782
$186.32
01810
$139.74
01820
$139.74
01829
$139.74
01830
$139.74
01832
$279.48
01840
$279.48
01842
$279.48
01844
$279.48
01850
$139.74
01852
$186.32
01860
$139.74
01916
$232.90
01920
$326.06
01922
$326.06
01924
$232.90
01925
$326.06
01926
$372.64
01930
$232.90
01931
$326.06
01932
$279.48
01933
$326.06
01935
$232.90
01936
$232.90Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Anesthesia
CPT Code
MAR
01951
$139.74
01952
$232.90
01953
$46.58
01958
$232.90
01960
$232.90
01961
$326.06
01962
$372.64
01963
$372.64
01965
$186.32
01966
$186.32
01967
$232.90
01968
$93.16
01969
$232.90
01990
$326.06
01991
$139.74
01992
$232.90
01996
$139.74
01999
BR
Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
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Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
Surgery
Ground Rules
SURGERY GROUND RULES
General Information and Instructions
1. PACKAGE OR GLOBAL FEE CONCEPT: The listed maximum allowable reimbursement (MAR) for all surgical procedures includes the surgery, local infiltration, digital block and/or topical anesthesia when used and the normal follow-up care for the period indicated in days in the follow-up days (FUD) column.
Regional or general anesthesia provided by the operating surgeon can be charged for by using the corresponding Basic Anesthesia Value only. Anesthesia Ground Rule 1(a) governs calculation of the maximum allowable reimbursement (MAR) for such anesthesia services.
Payment is for the procedure coded and described, irrespective of the method(s) or appliance(s) used to perform the procedure. The allowables are applicable to all physicians who perform the listed services.
2. IMMEDIATE PREOPERATIVE VISITS AND OTHER SERVICES BY THE SURGEON: Under most circumstances, including ordinary referrals, the immediate preoperative visit in the hospital or elsewhere necessary to examine the patient, complete the hospital records, and initiate the treatment program is included in the listed maximum allowable reimbursement (MAR) for the surgical procedure.
3. ADDITIONAL CHARGES MAY BE WARRANTED FOR PREOPERATIVE SERVICES UNDER THE FOLLOWING CIRCUMSTANCES:
a. when the preoperative visit is the initial visit (e.g., an emergency) and prolonged detention or evaluation is required to prepare the patient or to establish the need for and type of surgical procedure.
b. when the preoperative visit is an initial consultation.
c. when procedures not usually part of the basic surgical procedure (e.g., myelography prior to laminectomy, bronchoscopy prior to chest surgery) are provided during the immediate preoperative period.
4. FOLLOW-UP CARE FOR DIAGNOSTIC PROCEDURES (E.G., ENDOSCOPY, INJECTION PROCEDURES FOR RADIOGRAPHY): includes only that care related to recovery from the diagnostic procedure itself. Care of the condition for which the diagnostic procedure was performed or of other concomitant conditions is not included and may be charged for in accordance with the services rendered.
5. MULTIPLE OR BILATERAL PROCEDURES: When multiple procedures, unrelated to the major procedure and adding significant time or complexity are provided at the same operative session, reimbursement will be the major procedure at full value and fifty Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
Surgery
Ground Rules
percent (50%) for the lesser procedure(s), up to a total maximum of twice the allowable for the major procedure. Multiple procedures should be listed according to allowable amounts. The major procedure should reflect the greatest allowable. All other procedures should be listed in decreasing order of allowable amount. Multiple procedure guidelines do not apply to procedures flagged with a pound (#) sign. See Surgery Ground Rule 17.
The same rule applies for bilateral procedures when such are not specifically identified in the schedule.
Multiple related procedures shall not warrant any additional reimbursement except in those areas where separate codes are listed. Related procedures are those without which the principal procedure cannot be adequately performed.
EXAMPLES:
Related Procedures:
a. Open reduction of a fracture: The excision of a previous scar(s), the incision of fascia(s) and muscle(s), the identification and retraction of nerves, muscles and area structures and the closure of the wound irrespective of type of closure are all related to the principal procedure of the bone repair and merit no additional reimbursement.
b. Repair of a tendon: The skin incision and linear closure, as well as the identification, incision and retraction of adjacent or overlying structures are related to the principal procedure and merit no additional reimbursement.
Unrelated Procedures:
a. Multiple lacerations of an area such as the face when such lacerations are not continuous.
b. Fractures of arm (humerus) and of the forearm (radius and/or ulna) in the same extremity are considered as two (2) distinct areas and when treated by reduction and/or suturing, the unrelated procedures rule applies. If, however, these are treated in an office or out-patient site after the follow-up period(s) expires, they will be considered as related procedures.
For incidental procedures (e.g., incidental appendectomy, incidental scar excisions, puncture of ovarian cysts, lysis of adhesions, etc.) an additional reimbursement is not warranted. The closure of an incision or laceration incidental to the repair of deeper structures such as nerves, tendons, etc., does not merit any additional reimbursement irrespective of the method of closure.
Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
Surgery
Ground Rules
When more than one identifiable surgical procedure or service related to the care of the same entity is rendered during the total follow-up period, an additional reimbursement may be warranted. Identify each and reimburse as follows: The major procedure at full value and fifty percent (50%) for the lesser procedure(s) up to a total maximum of twice the greater value (e.g., unsuccessful closed reduction of a fracture followed on a different day by open reduction). Applying traction prior to either planned subsequent closed or open reduction shall not warrant additional reimbursement.
6. FOLLOW-UP OR AFTERCARE:
a. Follow-up care for therapeutic surgical procedures includes all normal postoperative care. Uncommon or unusual complications, recurrence or the presence of other diseases or injuries requiring significant additional services concurrent with the procedure(s) or during the listed period of follow-up care may warrant additional reimbursement. If such charges are made, explain by report with adequate description.
b. When an additional surgical procedure(s) is performed during the stated follow-up period and is related to the previously performed procedure(s) but is not an intrinsic part of the latter, the additional procedure will be paid at fifty percent (50%). In these instances, the follow-up periods will continue concurrently to their normal termination.
c. When multiple procedures and/or services are performed concurrently or sequentially within the same operative or treatment setting, the longest follow-up period will apply to all as one item.
7. SEPARATE OR INDEPENDENT PROCEDURES: Certain of the listed procedures are commonly carried out as an integral part of a total service, and as such do not warrant a separate charge. When such a procedure is carried out as a separate procedure not immediately related to other services, the indicated value for "Separate Procedure" is applicable.
8. PRIMARY, SECONDARY OR DELAYED PROCEDURES: A primary procedure refers to one that is attempted or performed for the first time, irrespective of the time relationship to the date of injury or the onset of the condition being treated. Secondary refers to treatment of a condition that has been specifically treated previously and is being treated subsequently. For example, where a tendon is lacerated and it is elected to close the laceration without suturing the tendon, the first direct repair of the tendon would constitute a delayed but primary repair. In this example, if the first repair is unsuccessful any subsequent repair of the tendon would be a secondary procedure. Delayed procedures have the same values as primary procedures.
9. OPERATIVE REPORT AND BILLING: A bill for an operative procedure(s) shall not be deemed properly submitted unless and until an operative report is received by the payer. If performed in a hospital operating site, a copy of the hospital operative report shall be Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
Surgery
Ground Rules
submitted. If in other sites, identify the location as well as submitting an informative description of the surgery performed.
10. BY REPORT ("BR") ITEMS: "BR" in the maximum allowable reimbursement (MAR) column indicates that the value of this service is to be determined "by report" because the service is too unusual or variable to be assigned a value. Pertinent information concerning the nature, extent and need for the procedure or service, the time, the skill and equipment necessary, etc., is to be furnished, using any of the following as indicated:
a. Diagnosis (postoperative), pertinent history and physical findings.
b. Size, location and number of lesion(s) or procedure(s) where appropriate.
c. Major surgical procedure with supplementary procedure(s).
d. Whenever possible, list the closest similar procedure by number and value. The "BR" value shall be consistent in value with other values in the schedule.
e. Estimated follow-up period, if not listed.
f. Operative time.
11. UNLISTED SERVICES OR PROCEDURES: A service or procedure that is not identified by a particular CPT7 code should be listed under the appropriate AUnlisted Procedure@. These procedures often have A99" as the final two digits. The "Unlisted Procedure" and accompanying code for SURGERY will be found at the end of the relevant section or subsection. Values should be substantiated Aby report@.
12. CONCURRENT SERVICES BY MORE THAN ONE PHYSICIAN: Charges for concurrent services of two or more physicians may be warranted under the following circumstances:
a. IDENTIFIABLE MEDICAL SERVICES: Identifiable medical services provided prior to or during the surgical procedure or in the postoperative period are to be charged for by the physician(s) rendering the service(s) identified by the appropriate code and value. Such services are unrelated to the surgeon's fees.
b. ASSISTANT SURGEON: Identify surgery performed by CPT7 number and description of procedure(s). The code(s) must coincide with those of the primary surgeon. Reimbursement will be at twenty percent (20%) of the code allowable.
Assistant surgeon fees are not payable when the hospital or ambulatory surgical center provides intern or resident staff to assist at surgery.
c. TWO SURGEONS: Under certain circumstances the skills of two surgeons (usually with different skills) may be required in the management of a specific surgical problem. When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding the modifier >-62' to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
Surgery
Ground Rules
continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s), including add-on procedure(s), are performed during the same surgical session, separate code(s) may also be reported with the modifier >-62' added. Under these circumstances, the total allowable may be increased by twenty-five percent (25%) in lieu of the assistant=s charges. By prior agreement, the total allowable for the procedure(s) may be apportioned in relation to the responsibility and work done. Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier >-80' or modifier >-82' added, as appropriate.
d. SURGICAL TEAM: Under some circumstances highly complex procedures (e.g., open heart or organ transplant surgery) requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel and various types of complex equipment are carried out under the "surgical team" concept with a single fee charged for the total service. The services covered vary widely and a single value cannot be assigned. The situations should be identified. The value should be supported by a report to include itemization of the physician services, paramedical personnel and equipment involved.
13. SURGERY AND FOLLOW-UP CARE PROVIDED BY DIFFERENT PHYSICIANS: When one physician performs the surgical procedure itself and another provides the follow-up care, the allowable may be apportioned between them by agreement and in accordance with medical ethics. Identify and indicate whether the value is for the procedure or the follow-up care, rather than the whole. The "global fee" is not increased, but pro-rated between the physicians.
14. PRORATION OF SCHEDULED ALLOWABLE: When the schedule specifies a maximum allowable reimbursement for a definite treatment with an inclusive period of after-care (follow-up days), and the patient is transferred from one to another physician, the employer or insurance carrier is only responsible for the total amount listed in the schedule, such amount to be apportioned between the physicians. The concerned physicians shall agree upon the amount of proration, and shall render separate bills accordingly.
15. REPEAT PROCEDURE BY ANOTHER PHYSICIAN: A basic procedure performed by another physician may have to be repeated. Identify and submit an explanatory note.
16. DURABLE MEDICAL EQUIPMENT AND SUPPLIES PROVIDED BY PHYSICIAN: Durable medical equipment and supplies provided by the physician over and above those usually included with the office visit or other services rendered are governed by the Durable Medical Equipment, Supplies, Orthotics and Prostheses Ground Rules.
Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
Surgery
Ground Rules
17. POUND (#) PROCEDURES: Procedures flagged with a pound (#) sign are valued at their appropriate level and Surgery Ground Rule 5 will not apply.
18. MEASUREMENTS IN CODED DESCRIPTORS: Measurements listed in coded descriptors are the original wound(s) or defect(s) before any treatment is effected. The stated maximum allowable(s) is inclusive of any additional creation of a defect and the necessary preparations for repair merit no additional reimbursement. The depth of a wound is not a factor in the measurements when the descriptor is stated in terms of length or square centimeters or square inches.
Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
10021
3
0
$151.30
10022
3
0
$165.40
10040
3
10
$99.18
10060
3
10
$108.05
10061
3
10
$206.32
10080
3
10
$179.63
10081
3
10
$279.87
10120
3
10
$145.50
10121
3
10
$285.21
10140
3
10
$149.67
10160
3
10
$125.96
10180
3
10
$309.65
11000
3
0
$78.29
11001
#
0
0
$37.27
11004
5
0
$871.04
11005
3
0
$1,194.01
11006
5
0
$1,096.14
11008
0
0
$450.20
11010
#
3
10
$738.41
11011
3
0
$714.44
11012
3
0
$978.70
11042
3
0
$177.63
11043
3
0
$333.07
11044
3
0
$476.39
11045
#
3
0
$53.78
11046
#
3
0
$94.00
11047
#
3
0
$154.53
11055
3
0
$50.66
11056
3
0
$68.51
11057
3
0
$88.08
11100
3
0
$132.29
11101
#
0
0
$57.42
11200
3
10
$87.82
11201
#
0
0
$32.95
11300
3
0
$97.87
11301
3
0
$142.40
11302
3
0
$170.88
11303
3
0
$208.86
11305
3
0
$113.92
11306
3
0
$161.39
11307
3
0
$189.87
11308
3
0
$216.66
11310
5
0
$127.23
11311
5
0
$170.88
11312
5
0
$199.36 CPT Code SURG ANES FUD MAR
11313
5
0
$265.81
11400
3
10
$123.24
11401
3
10
$145.26
11402
3
10
$166.20
11403
3
10
$187.32
11404
3
10
$214.50
11406
3
10
$383.89
11420
5
10
$121.34
11421
5
10
$155.30
11422
5
10
$181.57
11423
5
10
$219.94
11424
5
10
$274.03
11426
5
10
$343.21
11440
5
10
$142.76
11441
5
10
$175.95
11442
5
10
$208.94
11443
5
10
$263.93
11444
5
10
$313.19
11446
5
10
$388.53
11450
3
90
$535.94
11451
3
90
$655.04
11462
3
90
$577.62
11463
3
90
$655.04
11470
3
90
$635.39
11471
3
90
$738.41
11600
3
10
$173.04
11601
3
10
$286.75
11602
3
10
$313.59
11603
3
10
$356.67
11604
3
10
$289.58
11606
3
10
$559.49
11620
5
10
$182.33
11621
5
10
$244.67
11622
5
10
$322.97
11623
5
10
$401.27
11624
5
10
$479.56
11626
5
10
$557.86
11640
5
10
$264.25
11641
5
10
$355.64
11642
5
10
$446.19
11643
5
10
$541.12
11644
5
10
$636.06
11646
5
10
$753.60
11719
3
0
$29.36
11720
3
0
$47.47 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
11721
3
0
$74.02
11730
3
0
$105.54
11732
#
0
0
$68.51
11740
3
0
$58.72
11750
3
10
$297.75
11752
3
10
$451.03
11755
3
0
$176.16
11760
3
10
$303.79
11762
3
10
$446.19
11765
3
10
$172.75
11770
5
10
$274.08
11771
5
90
$774.13
11772
5
90
$952.79
11900
3
0
$53.63
11901
3
0
$66.75
11920
3
0
$302.85
11921
3
0
$565.19
11922
#
0
0
$403.70
11950
3
0
$123.15
11951
3
0
$226.07
11952
3
0
$452.15
11954
3
0
$195.74
11960
3
90
$1,321.24
11970
3
90
$1,211.11
11971
3
90
$483.55
11975
3
0
$111.45
11976
3
0
$159.90
11977
3
0
$332.95
11980
3
0
$117.98
11981
3
0
$150.15
11982
3
0
$175.88
11983
3
0
$283.82
12001
5
0
$161.58
12002
5
0
$175.39
12004
5
0
$206.87
12005
5
0
$254.42
12006
5
0
$316.51
12007
5
0
$358.44
12011
5
0
$171.42
12013
5
0
$189.45
12014
5
0
$224.21
12015
5
0
$282.27
12016
5
0
$338.05
12017
5
0
$303.71
12018
5
0
$359.55 CPT Code SURG ANES FUD MAR
12020
3
10
$288.42
12021
3
10
$176.16
12031
5
10
$310.18
12032
5
10
$390.47
12034
5
10
$389.70
12035
5
10
$384.69
12036
5
10
$431.72
12037
5
10
$485.47
12041
5
10
$324.18
12042
5
10
$371.47
12044
5
10
$439.32
12045
5
10
$397.97
12046
5
10
$474.70
12047
5
10
$493.75
12051
5
10
$256.71
12052
5
10
$391.62
12053
5
10
$321.76
12054
5
10
$364.73
12055
5
10
$441.07
12056
5
10
$539.04
12057
5
10
$579.16
13100
3
10
$321.25
13101
3
10
$384.36
13102
#
0
0
$146.80
13120
5
10
$333.75
13121
5
10
$411.97
13122
#
0
0
$146.80
13131
5
10
$365.76
13132
5
10
$747.92
13133
#
0
0
$185.90
13150
5
10
$388.89
13151
5
10
$416.19
13152
5
10
$619.72
13153
#
0
0
$225.10
13160
3
90
$822.55
14000
3
90
$774.13
14001
3
90
$893.24
14020
5
90
$758.09
14021
5
90
$984.25
14040
5
90
$1,044.72
14041
5
90
$1,429.17
14060
5
90
$1,359.25
14061
5
90
$1,516.98
14301
5
90
$1,916.72
14302
#
5
0
$411.89 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
14350
3
90
$952.79
15002
3
0
$365.67
15003
#
3
0
$79.56
15004
3
0
$444.72
15005
#
3
0
$135.53
15040
3
0
$288.97
15050
3
90
$714.12
15100
3
90
$948.29
15101
#
0
0
$232.44
15110
3
90
$975.40
15111
#
0
0
$142.05
15115
3
90
$956.97
15116
#
0
0
$189.74
15120
5
90
$1,310.08
15121
#
0
0
$401.27
15130
3
90
$771.94
15131
#
0
0
$116.03
15135
5
90
$958.20
15136
#
0
0
$109.70
15150
3
90
$807.44
15151
#
0
0
$150.47
15152
#
0
0
$191.42
15155
5
90
$824.30
15156
#
0
0
$204.62
15157
#
0
0
$225.86
15170
3
90
$468.24
15171
#
0
0
$108.22
15175
5
90
$620.11
15176
#
0
0
$172.16
15200
3
90
$789.08
15201
#
0
0
$195.74
15220
5
90
$822.24
15221
#
0
0
$242.22
15240
5
90
$1,131.43
15241
#
0
0
$322.96
15260
5
90
$1,429.17
15261
#
0
0
$484.45
15300
3
90
$378.48
15301
#
0
0
$71.76
15320
5
90
$432.76
15321
#
0
0
$106.97
15330
3
90
$344.06
15331
#
0
0
$71.32
15335
5
90
$373.30
15336
#
0
0
$102.22 CPT Code SURG ANES FUD MAR
15340
3
10
$353.79
15341
#
0
0
$52.20
15360
3
90
$395.27
15361
#
0
0
$82.20
15365
5
90
$399.83
15366
#
0
0
$101.45
15400
3
90
$517.72
15401
#
0
0
$137.02
15420
5
90
$463.73
15421
#
0
0
$129.60
15430
3
90
$589.76
15431
#
0
0
BR
15570
3
90
$978.70
15572
5
90
$1,272.30
15574
5
90
$1,272.30
15576
5
90
$1,076.57
15600
3
90
$556.46
15610
5
90
$577.62
15620
5
90
$655.04
15630
5
90
$750.91
15650
3
90
$882.52
15731
5
90
$1,248.04
15732
5
90
$2,055.26
15734
3
90
$1,859.52
15736
5
90
$1,859.52
15738
4
90
$1,859.52
15740
3
90
$1,114.46
15750
3
90
$1,174.44
15756
3
90
$4,164.48
15757
3
90
$4,131.50
15758
4
90
$4,112.73
15760
5
90
$1,071.88
15770
5
90
$1,179.05
15775
5
0
$360.50
15776
5
0
$498.27
15780
5
90
$978.70
15781
5
90
$536.26
15782
3
90
$604.67
15783
3
90
$493.33
15786
5
10
$237.72
15787
#
0
0
$78.29
15788
5
90
$767.96
15789
5
90
$970.46
15792
3
90
$586.40
15793
3
90
$808.68 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
15819
5
90
$1,837.35
15820
5
90
$982.54
15821
5
90
$1,031.67
15822
5
90
$835.16
15823
5
90
$1,057.10
15824
5
0
$812.31
15825
5
0
$694.88
15826
5
0
$587.22
15828
5
0
$1,986.75
15829
3
0
$1,986.75
15830
5
90
$1,323.54
15832
3
90
$1,631.02
15833
3
90
$1,631.02
15834
3
90
$1,631.02
15835
3
90
$1,631.02
15836
3
90
$1,190.98
15837
3
90
$988.51
15838
5
90
$942.46
15839
3
90
$1,076.57
15840
5
90
$1,937.78
15841
5
90
$2,740.35
15842
5
90
$3,425.44
15845
3
90
$2,018.52
15847
#
0
0
BR
15850
3
0
$208.10
15851
3
0
$282.59
15852
3
0
$145.33
15860
3
0
$201.85
15876
5
0
$479.56
15877
4
0
$861.25
15878
3
0
$479.56
15879
3
0
$861.25
15920
6
90
$660.74
15922
6
90
$839.01
15931
5
90
$697.92
15933
6
90
$1,076.57
15934
5
90
$969.38
15935
6
90
$1,272.30
15936
5
90
$1,006.38
15937
6
90
$1,419.11
15940
3
90
$782.96
15941
6
90
$1,076.57
15944
3
90
$990.89
15945
6
90
$1,174.44
15946
6
90
$1,957.39 CPT Code SURG ANES FUD MAR
15950
5
90
$601.56
15951
6
90
$862.21
15952
5
90
$892.21
15953
6
90
$1,071.94
15956
5
90
$1,233.39
15958
6
90
$1,321.24
15999
5
0
BR
16000
3
0
$76.82
16020
0
0
$89.79
16025
0
0
$163.34
16030
0
0
$195.74
16035
3
0
$419.86
16036
#
0
0
$201.85
17000
3
10
$107.19
17003
#
0
0
$16.15
17004
3
10
$314.41
17106
3
90
$500.21
17107
3
90
$810.35
17108
3
90
$1,215.51
17110
3
10
$140.08
17111
3
10
$128.98
17250
3
0
$79.15
17260
3
10
$127.23
17261
3
10
$166.38
17262
3
10
$225.10
17263
3
10
$254.46
17264
3
10
$274.03
17266
3
10
$332.75
17270
5
10
$165.68
17271
5
10
$205.53
17272
5
10
$244.67
17273
5
10
$293.61
17274
5
10
$362.12
17276
5
10
$436.70
17280
5
10
$156.59
17281
5
10
$244.67
17282
5
10
$283.82
17283
5
10
$366.60
17284
5
10
$465.17
17286
5
10
$607.57
17311
5
0
$762.64
17312
#
5
0
$457.50
17313
5
0
$695.79
17314
#
5
0
$423.72
17315
#
5
0
$90.84 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
17340
5
10
$59.55
17360
5
10
$128.89
17380
5
0
$68.51
17999
5
0
BR
19000
3
0
$124.33
19001
#
0
0
$32.17
19020
3
90
$439.56
19030
3
0
$190.65
19100
3
0
$149.50
19101
3
10
$344.71
19102
3
0
$255.95
19103
3
0
$634.07
19105
3
0
$2,264.09
19110
3
90
$512.12
19112
3
90
$500.21
19120
3
90
$595.49
19125
3
90
$808.68
19126
#
0
0
$282.59
19260
6
90
$1,663.78
19271
13
90
$2,695.94
19272
13
90
$3,130.79
19290
3
0
$182.33
19291
#
0
0
$88.08
19295
#
0
0
$161.48
19296
3
0
$5,177.84
19297
#
0
0
$146.80
19298
3
0
$1,922.02
19300
3
90
$574.16
19301
3
90
$591.49
19302
5
90
$981.98
19303
3
90
$1,019.99
19304
3
90
$610.12
19305
5
90
$1,222.49
19306
13
90
$1,269.12
19307
5
90
$1,275.33
19316
5
90
$1,272.30
19318
5
90
$1,761.65
19324
5
90
$536.09
19325
5
90
$1,044.27
19328
5
90
$494.61
19330
5
90
$697.14
19340
5
90
$1,376.54
19342
5
90
$1,518.94
19350
5
90
$987.89
19355
5
90
$777.48 CPT Code SURG ANES FUD MAR
19357
5
90
$2,348.87
19361
5
90
$2,960.23
19364
5
90
$3,523.31
19366
5
90
$2,906.67
19367
5
90
$3,175.92
19368
5
90
$3,927.12
19369
5
90
$3,625.51
19370
5
90
$750.76
19371
5
90
$858.01
19380
5
90
$780.06
19396
5 0 $308.02 19499 5
0
BR
20005
3
10
$315.07
20100
5
10
$1,065.78
20101
3
10
$418.28
20102
4
10
$511.62
20103
3
10
$655.73
20150
6
90
$1,718.21
20200
3
0
$198.74
20205
3
0
$278.78
20206
3
0
$306.31
20220
3
0
$238.10
20225
10
0
$1,031.32
20240
6
10
$274.03
20245
5
10
$664.95
20250
10
10
$1,550.23
20251
8
10
$1,267.64
20500
3
10
$147.64
20501
3
0
$151.89
20520
3
10
$213.93
20525
3
10
$534.41
20526
3
0
$85.33
20550
3
0
$66.16
20551
3
0
$65.37
20552
3
0
$61.37
20553
3
0
$145.33
20555
3
0
$401.69
20600
3
0
$59.84
20605
3
0
$65.33
20610
3
0
$78.80
20612
3
0
$64.41
20615
3
10
$362.12
20650
4
10
$209.65
20660
5
0
$255.92
20661
5
90
$474.09 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
20662
6
90
$598.30
20663
4
90
$598.30
20664
5
90
$1,021.72
20665
5
10
$149.41
20670
3
10
$538.18
20680
5
90
$582.35
20690
3
90
$600.78
20692
3
90
$1,081.41
20693
3
90
$543.08
20694
3
90
$488.56
20696
3
90
$1,260.06
20697
3
0
$2,141.82
20802
6
90
$5,248.16
20805
6
90
$5,248.16
20808
6
90
$5,872.18
20816
6
90
$3,012.38
20822
6
90
$2,621.75
20824
6
90
$3,131.83
20827
6
90
$2,785.91
20838
8
90
$5,248.16
20900
3
0
$609.61
20902
6
0
$570.38
20910
6
90
$570.69
20912
5
90
$570.69
20920
4
90
$438.95
20922
4
90
$639.66
20924
4
90
$570.54
20926
3
90
$474.65
20930
#
0
0
$0.00
20931
#
0
0
$226.07
20936
#
0
0
$0.00
20937
#
0
0
$331.04
20938
#
0
0
$363.33
20950
3
0
$331.87
20955
8
90
$4,925.20
20956
6
90
$4,925.20
20957
8
90
$4,925.20
20962
8
90
$3,038.82
20969
8
90
$3,283.09
20970
6
90
$4,946.36
20972
8
90
$4,925.20
20973
8
90
$4,925.20
20974
5
0
$242.22
20975
3
0
$303.79
20979
0
0
$161.48 CPT Code SURG ANES FUD MAR
20982
3
0
$4,719.05
20985
#
3
0
$180.25
20999
0
0
BR
21010
5
90
$1,234.14
21011
5
90
$573.94
21012
5
90
$606.81
21013
5
90
$888.39
21014
5
90
$936.55
21015
5
90
$759.47
21016
5
90
$1,852.92
21025
5
90
$980.67
21026
5
90
$949.34
21029
5
90
$1,076.57
21030
5
90
$1,049.63
21031
5
90
$645.54
21032
5
90
$587.22
21034
5
90
$1,565.91
21040
5
90
$771.68
21044
5
90
$1,509.44
21045
7
90
$3,148.90
21046
5
90
$1,144.93
21047
5
90
$1,503.18
21048
5
90
$1,176.85
21049
5
90
$1,451.83
21050
5
90
$1,531.53
21060
5
90
$1,424.00
21070
5
90
$1,534.08
21073
5
90
$398.75
21076
5
10
$1,698.46
21077
5
90
$6,136.31
21079
5
90
$1,941.07
21080
5
90
$2,197.66
21081
5
90
$2,000.20
21082
5
90
$1,787.57
21083
5
90
$1,691.56
21084
5
90
$1,971.75
21085
5
10
$780.27
21086
5
90
$2,138.00
21087
5
90
$2,120.09
21088
5
90
$932.09
21089
5
90
BR
21100
5
90
$683.78
21110
5
90
$803.91
21116
5
0
$206.67
21120
5
90
$1,100.94 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
21121
5
90
$1,341.71
21122
5
90
$1,574.45
21123
5
90
$1,816.67
21125
5
90
$3,873.55
21127
5
90
$4,740.27
21137
5
90
$1,388.75
21138
7
90
$1,816.67
21139
7
90
$1,937.78
21141
5
90
$2,400.37
21142
7
90
$2,420.58
21143
7
90
$2,559.37
21145
7
90
$2,659.18
21146
7
90
$3,027.79
21147
7
90
$3,310.38
21150
7
90
$1,942.11
21151
7
90
$2,331.55
21154
7
90
$2,474.91
21155
7
90
$3,193.33
21159
7
90
$5,813.35
21160
7
90
$6,400.90
21172
7
90
$3,915.94
21175
7
90
$4,682.98
21179
7
90
$2,825.93
21180
7
90
$3,310.38
21181
7
90
$1,234.14
21182
7
90
$3,515.43
21183
7
90
$3,954.42
21184
7
90
$4,352.51
21188
7
90
$2,842.92
21193
7
90
$2,422.23
21194
7
90
$3,407.27
21195
7
90
$2,906.67
21196
7
90
$3,068.16
21198
7
90
$1,859.52
21199
7
90
$1,810.40
21206
7
90
$2,122.61
21208
7
90
$2,309.62
21209
7
90
$1,534.08
21210
5
90
$2,026.29
21215
5
90
$4,805.91
21230
5
90
$1,534.08
21235
5
90
$1,273.12
21240
5
90
$2,139.64
21242
5
90
$2,260.75
21243
5
90
$2,740.35 CPT Code SURG ANES FUD MAR
21244
5
90
$2,099.26
21245
7
90
$1,830.98
21246
7
90
$2,987.42
21247
7
90
$3,148.90
21248
7
90
$1,468.04
21249
7
90
$1,761.65
21255
7
90
$2,309.44
21256
7
90
$4,440.75
21260
7
90
$3,148.90
21261
11
90
$5,248.16
21263
7
90
$5,248.16
21267
7
90
$3,148.90
21268
11
90
$5,248.16
21270
5
90
$1,613.87
21275
7
90
$896.33
21280
5
90
$1,372.60
21282
5
90
$1,090.00
21295
5
90
$888.15
21296
5
90
$1,211.11
21299
5
90
BR
21310
5
0
$118.81
21315
5
10
$345.72
21320
5
10
$398.72
21325
5
90
$522.94
21330
5
90
$978.70
21335
5
90
$1,453.34
21336
5
90
$802.53
21337
5
90
$386.89
21338
5
90
$1,298.85
21339
5
90
$1,401.27
21340
5
90
$1,372.83
21343
5
90
$1,370.17
21344
5
90
$2,545.48
21345
7
90
$978.70
21346
7
90
$1,468.04
21347
7
90
$1,683.36
21348
7
90
$2,212.30
21355
5
10
$775.48
21356
5
10
$857.13
21360
7
90
$1,073.85
21365
7
90
$1,468.04
21366
7
90
$2,217.50
21385
7
90
$1,229.09
21386
7
90
$1,453.34
21387
7
90
$1,453.34 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
21390
7
90
$1,534.08
21395
7
90
$2,083.11
21400
5
90
$177.24
21401
5
90
$1,130.37
21406
7
90
$1,291.86
21407
7
90
$1,453.34
21408
7
90
$1,663.27
21421
5
90
$1,186.67
21422
7
90
$1,211.11
21423
7
90
$1,719.78
21431
5
90
$1,291.86
21432
7
90
$1,534.08
21433
7
90
$2,153.13
21435
7
90
$2,278.40
21436
7
90
$3,219.91
21440
7
90
$1,283.33
21445
7
90
$1,579.48
21450
5
90
$740.76
21451
5
90
$782.96
21452
5
90
$624.66
21453
5
90
$881.44
21454
5
90
$1,211.11
21461
5
90
$2,589.47
21462
5
90
$2,751.53
21465
5
90
$1,419.11
21470
5
90
$1,859.52
21480
5
0
$226.07
21485
5
90
$851.47
21490
5
90
$1,272.30
21495
5
90
$1,534.08
21497
5
90
$1,168.09
21499
0
90
BR
21501
5
90
$543.08
21502
6
90
$754.78
21510
10
90
$521.87
21550
5
10
$249.39
21552
5
90
$794.34
21554
5
90
$1,306.27
21555
5
90
$444.76
21556
5
90
$598.30
21557
6
90
$1,424.00
21558
5
90
$2,429.99
21600
6
90
$662.73
21610
6
90
$1,979.96
21615
6
90
$1,579.48 CPT Code SURG ANES FUD MAR
21616
6
90
$2,012.32
21620
6
90
$1,974.35
21627
10
90
$928.56
21630
13
90
$2,467.94
21632
12
90
$3,948.70
21685
12
90
$1,051.14
21700
5
90
$748.29
21705
6
90
$1,237.77
21720
5
90
$758.92
21725
5
90
$925.57
21740
13
90
$1,937.78
21742
10
90
BR
21743
12
90
BR
21750
10
90
$1,614.82
21800
6
90
$119.66
21805
6
90
$987.18
21810
10
90
$2,369.22
21820
6
90
$250.59
21825
10
90
$987.18
21899
0
30
BR
21920
5
10
$329.56
21925
5
90
$438.31
21930
5
90
$485.90
21931
5
90
$829.09
21932
5
90
$1,182.28
21933
5
90
$1,303.07
21935
5
90
$1,468.04
21936
5
90
$2,528.13
22010
5
90
$1,024.80
22015
5
90
$1,016.49
22100
10
90
$1,084.23
22101
10
90
$911.95
22102
8
90
$948.70
22103
#
0
0
$274.52
22110
10
90
$1,355.29
22112
10
90
$1,355.29
22114
8
90
$1,288.64
22116
#
0
0
$274.52
22206
13
90
$2,763.17
22207
13
90
$2,726.89
22208
#
13
0
$698.67
22210
13
90
$3,046.21
22212
13
90
$2,534.90
22214
13
90
$2,549.02
22216
#
0
0
$726.67 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
22220
10
90
$2,767.43
22222
10
90
$2,598.93
22224
8
90
$2,729.24
22226
#
0
0
$726.67
22305
8
90
$244.67
22310
8
90
$355.99
22315
0
90
$944.47
22318
10
90
$2,782.97
22319
10
90
$3,091.05
22325
8
90
$1,761.65
22326
10
90
$2,468.27
22327
10
90
$2,314.80
22328
#
0
0
$565.19
22505
3
10
$182.47
22520
5
10
$2,896.34
22521
5
10
$2,641.38
22522
#
0
0
$410.12
22523
5
10
$713.66
22524
5
10
$683.49
22525
#
0
0
$322.14
22526
5
10
$2,338.54
22527
#
0
0
$1,897.79
22532
10
90
$1,830.83
22533
8
90
$1,717.67
22534
#
0
0
$432.79
22548
13
90
$3,275.21
22551
13
90
$3,692.29
22552
#
13
0
$700.62
22554
10
90
$2,186.46
22556
10
90
$2,848.01
22558
8
90
$2,658.14
22585
#
0
0
$645.93
22590
10
90
$2,691.93
22595
10
90
$2,583.71
22600
10
90
$2,190.48
22610
10
90
$2,152.79
22612
8
90
$2,760.33
22614
#
0
0
$726.67
22630
8
90
$2,652.68
22632
#
0
0
$695.01
22800
13
90
$2,422.23
22802
13
90
$3,674.63
22804
13
90
$4,239.88
22808
13
90
$3,180.82
22810
13
90
$3,544.74 CPT Code SURG ANES FUD MAR
22812
13
90
$3,862.31
22818
13
90
$3,523.31
22819
13
90
$4,061.59
22830
13
90
$1,453.34
22840
#
13
0
$1,087.76
22841
#
10
0
BR
22842
#
13
0
$1,453.34
22843
#
13
0
$1,574.45
22844
#
13
0
$1,776.30
22845
#
13
0
$1,372.60
22846
#
13
0
$1,453.34
22847
#
13
0
$1,614.82
22848
#
13
0
$686.30
22849
13
90
$1,520.63
22850
13
90
$978.70
22851
#
13
0
$767.04
22852
13
90
$1,182.48
22855
13
90
$1,255.88
22856
13
90
$1,899.36
22857
13
90
$1,752.60
22861
13
90
$2,344.96
22862
13
90
$2,108.19
22864
13
90
$2,144.84
22865
13
90
$2,085.64
22899
3
90
BR
22900
4
90
$598.30
22901
4
90
$1,161.00
22902
4
90
$762.91
22903
4
90
$780.93
22904
4
90
$1,815.12
22905
4
90
$2,360.53
22999
4
0
BR
23000
5
90
$745.58
23020
5
90
$1,187.04
23030
5
10
$462.05
23031
5
10
$447.84
23035
5
90
$1,184.61
23040
5
90
$1,241.04
23044
5
90
$837.62
23065
3
10
$239.32
23066
5
90
$526.20
23071
5
90
$738.83
23073
5
90
$1,224.84
23075
3
90
$507.41
23076
5
90
$637.55 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
23077
5
90
$1,468.04
23078
5
90
$2,455.92
23100
5
90
$1,123.86
23101
5
90
$1,123.86
23105
5
90
$1,211.11
23106
5
90
$968.89
23107
5
90
$1,138.13
23120
5
90
$898.62
23125
6
90
$1,579.48
23130
5
90
$898.62
23140
5
90
$745.58
23145
5
90
$910.18
23146
5
90
$734.02
23150
5
90
$1,184.61
23155
5
90
$1,367.43
23156
5
90
$1,165.35
23170
5
90
$602.03
23172
5
90
$717.96
23174
5
90
$1,194.01
23180
5
90
$777.23
23182
5
90
$760.03
23184
5
90
$1,196.60
23190 5 90 $782.40 23195
5
90
$1,480.77
23200
6
90
$1,435.92
23210
6
90
$1,857.12
23220
6
90
$1,857.12
23330
3
10
$702.45
23331
6
90
$1,085.90
23332
10
90
$1,528.04
23350
4
0
$185.27
23395
5
90
$1,385.69
23397
5
90
$1,500.35
23400
5
90
$1,687.88
23405
5
90
$1,021.72
23406
5
90
$1,350.78
23410
5
90
$1,370.17
23412
5
90
$1,484.62
23415
5
90
$1,196.60
23420
5
90
$1,683.71
23430
5
90
$1,174.44
23440
5
90
$1,174.44
23450
5
90
$1,604.34
23455
5
90
$1,750.09
23460
5
90
$1,900.06 CPT Code SURG ANES FUD MAR
23462
5
90
$1,809.02
23465
5
90
$1,859.52
23466
5
90
$1,898.67
23470
5
90
$1,957.39
23472
10
90
$2,825.93
23480
5
90
$978.70
23485
5
90
$1,272.30
23490
5
90
$951.12
23491
5
90
$1,164.87
23500
5
90
$266.94
23505
5
90
$371.66
23515
5
90
$880.83
23520
4
90
$239.32
23525
4
90
$363.24
23530
5
90
$782.96
23532
5
90
$1,044.27
23540
4
90
$229.58
23545
4
90
$332.91
23550
5
90
$1,139.05
23552
5
90
$1,134.53
23570
5
90
$237.24
23575
5
90
$405.24
23585
5
90
$1,125.50
23600
4
90
$334.14
23605
4
90
$504.77
23615
5
90
$1,174.44
23616
5
90
$2,317.27
23620
4
90
$270.70
23625
4
90
$402.61
23630
5
90
$890.62
23650
0
90
$323.72
23655
4
90
$469.44
23660
5
90
$1,001.57
23665
4
90
$445.80
23670
5
90
$1,091.74
23675
4
90
$588.16
23680
5
90
$1,376.54
23700
4
10
$334.30
23800
5
90
$1,782.07
23802
5
90
$1,993.60
23900
15
90
$2,363.50
23920
9
90
$1,803.74
23921
3
90
$598.30
23929
5
0
BR
23930
3
10
$395.08 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
23931
3
10
$323.02
23935
4
90
$717.96
24000
4
90
$1,085.90
24006
4
90
$1,404.83
24065
3
10
$235.06
24066
3
90
$629.01
24071
3
90
$720.48
24073
3
90
$1,229.45
24075
3
90
$500.24
24076
3
90
$598.30
24077
6
90
$1,174.44
24079
3
90
$2,265.15
24100
4
90
$704.74
24101
4
90
$1,085.90
24102
4
90
$1,170.74
24105
3
90
$580.35
24110
5
90
$1,005.89
24115
5
90
$1,267.27
24116
5
90
$1,076.57
24120
4
90
$903.10
24125
4
90
$977.81
24126
4
90
$880.83
24130
3
90
$869.25
24134
4
90
$1,295.16
24136
3
90
$1,184.61
24138
3
90
$1,184.61
24140
4
90
$1,226.97
24145
3
90
$957.28
24147
3
90
$902.05
24149
6
90
$1,898.67
24150
6
90
$1,625.64
24152
6
90
$1,424.00
24155
4
90
$1,437.49
24160
4
90
$1,043.62
24164
4
90
$854.67
24200
3
10
$220.63
24201
3
90
$613.04
24220
3
0
$206.88
24300
3
90
$489.35
24301
3
90
$1,382.05
24305
3
90
$690.35
24310
5
90
$598.30
24320
5
90
$1,372.60
24330
3
90
$1,076.57
24331
3
90
$1,357.55 CPT Code SURG ANES FUD MAR
24332
3
90
$861.25
24340
5
90
$1,130.37
24341
3
90
$1,234.14
24342
3
90
$1,329.07
24343
4
90
$1,135.29
24344
4
90
$1,712.72
24345
4
90
$1,135.29
24346
4
90
$1,712.72
24357
4
90
$598.30
24358
4
90
$582.44
24359
4
90
$738.07
24360
4
90
$1,776.30
24361
4
90
$1,776.30
24362
4
90
$1,857.04
24363
7
90
$2,611.78
24365
4
90
$1,103.25
24366
4
90
$1,179.90
24400
5
90
$1,331.03
24410
5
90
$1,516.98
24420
5
90
$1,516.98
24430
5
90
$1,663.78
24435
5
90
$1,863.68
24470
4
90
$831.89
24495
3
90
$1,184.61
24498
5
90
$998.77
24500
3
90
$362.43
24505
3
90
$616.57
24515
4
90
$1,499.95
24516
4
90
$1,493.49
24530
3
90
$391.54
24535
3
90
$669.99
24538
3
90
$880.83
24545
4
90
$1,323.62
24546
4
90
$1,813.32
24560
3
90
$326.17
24565
3
90
$550.08
24566
3
90
$782.93
24575
4
90
$978.70
24576
3
90
$341.27
24577
3
90
$572.24
24579
4
90
$978.70
24582
3
90
$858.01
24586
4
90
$1,507.19
24587
4
90
$1,890.84
24600
0
90
$396.93 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
24605
3
90
$495.69
24615
4
90
$1,037.42
24620
3
90
$614.05
24635
4
90
$1,213.56
24640
3
10
$213.87
24650
3
90
$264.05
24655
3
90
$461.34
24665
3
90
$782.96
24666
3
90
$910.18
24670
3
90
$297.62
24675
3
90
$486.87
24685
3
90
$812.31
24800
4
90
$1,408.67
24802
3
90
$1,735.44
24900
6
90
$978.70
24920
6
90
$890.62
24925
6
90
$609.16
24930
6
90
$880.83
24931
6
90
$1,125.50
24935
6
90
$1,468.04
24940
4
90
$1,468.04
24999
4
0
BR
25000
3
90
$543.08
25001
3
90
$518.71
25020
3
90
$682.40
25023
3
90
$1,233.35
25024
3
90
$1,203.79
25025
3
90
$1,896.60
25028
3
90
$580.98
25031
3
90
$517.18
25035
3
90
$902.60
25040
3
90
$667.67
25065
3
10
$322.49
25066
3
90
$482.76
25071
3
90
$757.66
25073
3
90
$947.39
25075
3
90
$607.72
25076
3
90
$631.83
25077
3
90
$1,174.44
25078
3
90
$1,980.32
25085
3
90
$644.32
25100
3
90
$593.28
25101
3
90
$696.61
25105
3
90
$839.69
25107
3
90
$837.62 CPT Code SURG ANES FUD MAR
25109
3
90
$584.43
25110
3
90
$472.49
25111
3
90
$543.08
25112
3
90
$661.74
25115
3
90
$1,196.60
25116
3
90
$1,083.65
25118
3
90
$691.03
25119
3
90
$987.18
25120
3
90
$908.96
25125
3
90
$1,027.63
25126
3
90
$929.76
25130
3
90
$717.96
25135
3
90
$782.96
25136
3
90
$587.22
25145
3
90
$998.86
25150
3
90
$763.99
25151
3
90
$902.05
25170
3
90
$1,741.05
25210
3
90
$837.62
25215
3
90
$1,079.92
25230
3
90
$644.32
25240
3
90
$644.32
25246
3
0
$205.76
25248
3
90
$604.96
25250
3
90
$987.18
25251
6
90
$1,480.77
25259
3
90
$489.35
25260
3
90
$957.28
25263
3
90
$1,021.72
25265
3
90
$1,052.35
25270
3
90
$772.84
25272
3
90
$853.96
25274
3
90
$970.38
25275
3
90
$1,096.14
25280
3
90
$865.23
25290
3
90
$833.61
25295
3
90
$804.23
25300
3
90
$929.76
25301
3
90
$831.89
25310
3
90
$959.12
25312
3
90
$1,174.44
25315
3
90
$1,099.76
25316
3
90
$1,275.29
25320
3
90
$1,468.04
25332
3
90
$1,424.00 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
25335
3
90
$1,474.67
25337
3
90
$1,321.24
25350
3
90
$1,008.05
25355
3
90
$1,203.79
25360
3
90
$1,008.05
25365
3
90
$1,409.32
25370
3
90
$1,296.78
25375
3
90
$1,637.37
25390
3
90
$1,106.96
25391
3
90
$1,428.90
25392
3
90
$1,468.04
25393
3
90
$1,761.65
25394
3
90
$1,272.30
25400
3
90
$1,174.44
25405
3
90
$1,426.94
25415
3
90
$1,663.78
25420
3
90
$1,937.81
25425
3
90
$1,493.88
25426
3
90
$1,859.52
25430
3
90
$1,125.50
25431
3
90
$1,115.71
25440
3
90
$1,321.24
25441
3
90
$1,370.17
25442
3
90
$914.49
25443
3
90
$1,076.57
25444
3
90
$1,076.57
25445
3
90
$1,076.57
25446
6
90
$2,044.18
25447
3
90
$1,423.86
25449
3
90
$1,171.48
25450
3
90
$793.08
25455
3
90
$885.96
25490
3
90
$1,012.81
25491
3
90
$1,063.96
25492
3
90
$1,215.88
25500
3
90
$276.08
25505
3
90
$533.31
25515
3
90
$890.62
25520
3
90
$851.47
25525
3
90
$1,364.52
25526
3
90
$2,083.11
25530
3
90
$395.38
25535
3
90
$508.62
25545
3
90
$880.83
25560
3
90
$349.77 CPT Code SURG ANES FUD MAR
25565
3
90
$708.76
25574
3
90
$851.47
25575
3
90
$1,340.82
25600
3
90
$358.98
25605
3
90
$593.03
25606
3
90
$765.52
25607
3
90
$801.63
25608
3
90
$911.34
25609
3
90
$1,162.95
25622
3
90
$423.41
25624
3
90
$489.43
25628
3
90
$750.76
25630
3
90
$423.41
25635
3
90
$506.26
25645
3
90
$640.82
25650
3
90
$532.71
25651
3
90
$665.51
25652
3
90
$988.48
25660
3
90
$431.85
25670
3
90
$773.17
25671
3
90
$812.31
25675
3
90
$458.80
25676
3
90
$782.96
25680
3
90
$494.92
25685
3
90
$1,076.57
25690
3
90
$510.04
25695
3
90
$1,090.92
25800
3
90
$1,223.37
25805
3
90
$1,473.30
25810
3
90
$1,370.17
25820
3
90
$1,055.79
25825
3
90
$1,263.40
25830
3
90
$1,321.24
25900
3
90
$963.52
25905
3
90
$935.09
25907
3
90
$848.09
25909
3
90
$953.13
25915
3
90
$1,565.24
25920
3
90
$812.31
25922
3
90
$652.94
25924
3
90
$822.10
25927
3
90
$978.70
25929
3
90
$625.32
25931
3
90
$978.70
25999
3
0
BR Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
26010
3
10
$295.94
26011
3
10
$458.26
26020
3
90
$607.50
26025
3
90
$662.73
26030
3
90
$888.46
26034
3
90
$717.96
26035
3
90
$1,455.17
26037
3
90
$1,184.61
26040
3
90
$358.98
26045
3
90
$598.30
26055
3
90
$704.36
26060
3
90
$303.76
26070
3
90
$521.68
26075
3
90
$547.63
26080
3
90
$543.08
26100
3
90
$560.18
26105
3
90
$568.26
26110
3
90
$526.78
26111
3
90
$740.70
26113
3
90
$971.47
26115
3
90
$710.24
26116
3
90
$598.30
26117
3
90
$1,139.20
26118
3
90
$1,896.70
26121
3
90
$1,028.15
26123
3
90
$1,331.12
26125
#
0
0
$488.54
26130
3
90
$759.47
26135
3
90
$880.83
26140
3
90
$782.96
26145
3
90
$854.40
26160
3
90
$647.44
26170
3
90
$543.08
26180
3
90
$598.30
26185
3
90
$580.77
26200
3
90
$738.84
26205
3
90
$734.02
26210
3
90
$644.32
26215
3
90
$636.15
26230
3
90
$662.73
26235
3
90
$598.30
26236
3
90
$598.30
26250
3
90
$949.34
26260
3
90
$996.80
26262
3
90
$949.34 CPT Code SURG ANES FUD MAR
26320
3
90
$580.35
26340
3
90
$440.41
26350
3
90
$874.99
26352
3
90
$1,125.50
26356
3
90
$1,150.79
26357
3
90
$1,042.40
26358
3
90
$1,223.37
26370
3
90
$957.28
26372
3
90
$1,353.08
26373
3
90
$1,037.80
26390
3
90
$978.00
26392
3
90
$1,316.26
26410
3
90
$702.15
26412
3
90
$841.29
26415
3
90
$1,021.72
26416
3
90
$1,196.60
26418
3
90
$698.56
26420
3
90
$874.50
26426
3
90
$824.85
26428
3
90
$913.14
26432
3
90
$717.96
26433
3
90
$717.96
26434
3
90
$782.96
26437
3
90
$752.42
26440
3
90
$780.14
26442
3
90
$1,032.93
26445
3
90
$733.33
26449
3
90
$1,013.37
26450
3
90
$479.16
26455
3
90
$598.30
26460
3
90
$453.62
26471
3
90
$735.60
26474
3
90
$712.75
26476
3
90
$688.29 26477 3 90 $692.62
26478
3
90
$755.32
26479
3
90
$741.73
26480
3
90
$929.79
26483
3
90
$1,174.44
26485
3
90
$1,008.05
26489
3
90
$1,301.66
26490
3
90
$998.27
26492
3
90
$1,291.88
26494
3
90
$1,174.44
26496
3
90
$1,370.17 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
26497
3
90
$1,174.44
26498
3
90
$1,614.85
26499
3
90
$1,410.14
26500
3
90
$746.73
26502
3
90
$828.84
26508
3
90
$782.96
26510
3
90
$782.96
26516
3
90
$836.52
26517
3
90
$970.35
26518
3
90
$1,096.14
26520
3
90
$812.30
26525
3
90
$817.05
26530
3
90
$782.96
26531
3
90
$978.70
26535
3
90
$702.19
26536
3
90
$978.70
26540
3
90
$1,027.63
26541
3
90
$1,125.50
26542
3
90
$978.70
26545
3
90
$821.21
26546
3
90
$1,077.49
26548
3
90
$903.62
26550
3
90
$2,153.13
26551
6
90
$5,278.62
26553
6
90
$5,221.34
26554
6
90
$5,780.20
26555
3
90
$1,535.20
26556
6
90
$5,040.04
26560
3
90
$990.10
26561
3
90
$1,615.69
26562
3
90
$1,565.91
26565
3
90
$831.89
26567
3
90
$809.24
26568
3
90
$1,060.49
26580
3
90
$1,957.39
26587
3
90
$1,078.29
26590
3
90
$1,443.85
26591
3
90
$685.09
26593
3
90
$702.43
26596
3
90
$1,174.44
26600
3
90
$353.90
26605
3
90
$330.95
26607
3
90
$598.30
26608
3
90
$814.00
26615
3
90
$812.49 CPT Code SURG ANES FUD MAR
26641
3
90
$383.79
26645
3
90
$478.64
26650
3
90
$814.41
26665
3
90
$1,067.89
26670
0
90
$347.96
26675
3
90
$460.80
26676
3
90
$545.45
26685
3
90
$717.96
26686
3
90
$957.28
26700
0
90
$333.09
26705
3
90
$428.71
26706
3
90
$478.64
26715
3
90
$812.49
26720
3
90
$198.11
26725
3
90
$357.13
26727
3
90
$511.74
26735
3
90
$717.96
26740
3
90
$303.76
26742
3
90
$423.41
26746
3
90
$743.23
26750
3
90
$186.21
26755
3
90
$328.01
26756
3
90
$449.48
26765
3
90
$495.49
26770
0
90
$281.88
26775
3
90
$398.36
26776
3
90
$479.14
26785
3
90
$676.99
26820
3
90
$1,154.86
26841
3
90
$877.09
26842
3
90
$988.48
26843
3
90
$863.76
26844
3
90
$988.48
26850
3
90
$826.49
26852
3
90
$932.44
26860
3
90
$675.18
26861
#
0
0
$183.75
26862
3
90
$851.24
26863
#
0
0
$293.61
26910
3
90
$828.84
26951
3
90
$701.57
26952
3
90
$837.62
26989
3
0
BR
26990
6
90
$675.98
26991
6
90
$772.13 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
26992
6
90
$1,088.56
27000
4
90
$502.09
27001
4
90
$604.83
27003
4
90
$837.62
27005
4
90
$814.23
27006
4
90
$838.78
27025
4
90
$1,019.29
27027
4
90
$999.09
27030
6
90
$1,370.17
27033
6
90
$1,379.96
27035
6
90
$1,683.36
27036
6
90
$1,614.85
27040
3
10
$358.06
27041
3
90
$769.91
27043
3
90
$829.09
27045
3
90
$1,316.26
27047
3
90
$667.31
27048
6
90
$598.30
27049
10
90
$1,468.04
27050
8
90
$587.22
27052
6
90
$1,090.00
27054
6
90
$1,630.97
27057
6
90
$1,109.89
27059
3
90
$3,228.13
27060
4
90
$662.73
27062
4
90
$503.87
27065
6
90
$598.30
27066
6
90
$929.76
27067
6
90
$1,174.44
27070
8
90
$919.41
27071
6
90
$1,435.92
27075
10
90
$2,562.75
27076
10
90
$3,037.87
27077
10
90
$4,404.13
27078
10
90
$2,484.25
27080
6
90
$587.22
27086
6
10
$271.90
27087
6
90
$706.25
27090
6
90
$1,370.17
27091
10
90
$3,229.64
27093
0
0
$240.08
27095
4
0
$391.48
27096
4
0
$293.61
27097
4
90
$712.91
27098
4
90
$1,139.20 CPT Code SURG ANES FUD MAR
27100
4
90
$1,376.54
27105
4
90
$1,471.47
27110
4
90
$1,670.73
27111
4
90
$1,534.08
27120
6
90
$2,254.77
27122
6
90
$2,018.52
27125
8
90
$2,180.01
27130
8
90
$2,624.08
27132
8
90
$2,940.65
27134
10
90
$3,383.25
27137
10
90
$2,589.19
27138
10
90
$2,694.28
27140
6
90
$1,194.01
27146
6
90
$2,183.47
27147
6
90
$2,468.27
27151
6
90
$2,468.27
27156
6
90
$2,838.22
27158
6
90
$2,183.47
27161
6
90
$1,761.65
27165
6
90
$2,270.58
27170
6
90
$2,055.97
27175
4
90
$1,076.57
27176
6
90
$1,735.93
27177
6
90
$1,934.69
27178
6
90
$1,840.89
27179
6
90
$1,614.85
27181
6
90
$1,953.93
27185
6
90
$791.59
27187
6
90
$2,825.93
27193
4
90
$714.44
27194
4
90
$819.86
27200
6
90
$193.30
27202
6
90
$1,015.86
27215
6
90
$1,136.27
27216
4
90
$2,527.19
27217
8
90
$2,018.52
27218
8
90
$2,890.52
27220
4
90
$549.96
27222
4
90
$1,055.79
27226
10
90
$2,188.08
27227
10
90
$4,206.61
27228
10
90
$6,725.72
27230
4
90
$506.25
27232
4
90
$978.70
27235
4
90
$1,695.56 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
27236
6
90
$2,180.01
27238
4
90
$491.38
27240
4
90
$1,096.79
27244
6
90
$1,928.03
27245
6
90
$2,163.77
27246
4
90
$423.32
27248
6
90
$865.39
27250
0
0
$438.27
27252
4
90
$831.42
27253
6
90
$1,613.87
27254
6
90
$2,209.28
27256
0
10
$668.24
27257
4
10
$1,184.61
27258
6
90
$1,761.65
27259
6
90
$1,859.52
27265
0
90
$437.39
27266
4
90
$642.33
27267
4
90
$466.25
27268
4
90
$580.28
27269
4
90
$1,411.70
27275
4
10
$306.60
27280
8
90
$1,370.17
27282
8
90
$1,453.34
27284
6
90
$2,642.48
27286
6
90
$2,848.01
27290
15
90
$3,229.64
27295
10
90
$2,215.11
27299
6
0
BR
27301
4
90
$718.45
27303
6
90
$722.95
27305
4
90
$717.96
27306
4
90
$423.77
27307
4
90
$517.58
27310
4
90
$1,199.82
27323
3
10
$258.27
27324
4
90
$419.55
27325
4
90
$589.91
27326
3
90
$548.13
27327
3
90
$471.78
27328
4
90
$598.30
27329
8
90
$1,370.17
27330
4
90
$1,009.26
27331
4
90
$1,090.00
27332
4
90
$1,291.86
27333
4
90
$1,299.93 CPT Code SURG ANES FUD MAR
27334
4
90
$1,453.34
27335
4
90
$1,534.08
27337
4
90
$741.18
27339
4
90
$1,333.87
27340
4
90
$789.74
27345
4
90
$888.46
27347
4
90
$734.02
27350
4
90
$1,184.61
27355
5
90
$1,085.90
27356
5
90
$1,271.58
27357
5
90
$1,405.98
27358
#
0
0
$1,291.86
27360
5
90
$1,174.44
27364
5
90
$2,772.28
27365
5
90
$2,523.99
27370
3
0
$194.16
27372
4
90
$662.59
27380
4
90
$1,018.09
27381
4
90
$1,272.30
27385
4
90
$1,088.44
27386
4
90
$1,434.75
27390
4
90
$717.96
27391
4
90
$947.72
27392
4
90
$1,220.28
27393
4
90
$837.62
27394
4
90
$1,076.94
27395
4
90
$1,508.91
27396
4
90
$1,308.01
27397
4
90
$1,578.54
27400
4
90
$1,211.11
27403
4
90
$1,372.60
27405
4
90
$1,167.56
27407
4
90
$1,372.60
27409
4
90
$1,673.55
27412
4
90
$2,485.89
27415
4
90
$2,074.84
27416
4
90
$1,111.31
27418
4
90
$1,695.56
27420
4
90
$1,290.05
27422
4
90
$1,284.70
27424
4
90
$1,332.23
27425
4
90
$1,291.86
27427
4
90
$1,534.08
27428
4
90
$2,180.01
27429
4
90
$2,422.23 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
27430
4
90
$1,278.61
27435
4
90
$1,367.04
27437
4
90
$1,211.11
27438
4
90
$1,614.82
27440
4
90
$1,695.56
27441
4
90
$1,776.30
27442
4
90
$1,857.04
27443
4
90
$1,776.30
27445
4
90
$2,422.23
27446
4
90
$2,260.75
27447
7
90
$3,068.16
27448
6
90
$1,493.71
27450
6
90
$1,764.99
27454
6
90
$2,006.33
27455
4
90
$1,272.30
27457
4
90
$1,516.98
27465
5
90
$1,993.68
27466
5
90
$2,139.64
27468
5
90
$3,108.53
27470
6
90
$1,976.72
27472
6
90
$2,183.47
27475
5
90
$1,138.45
27477
4
90
$1,299.93
27479
5
90
$1,655.19
27485
5
90
$1,086.35
27486
7
90
$1,536.78
27487
7
90
$3,633.34
27488
7
90
$1,340.65
27495
6
90
$1,370.17
27496
4
90
$704.66
27497
4
90
$1,025.41
27498
4
90
$1,170.74
27499
4
90
$1,606.74
27500
4
90
$792.75
27501
4
90
$792.75
27502
4
90
$870.76
27503
4
90
$1,252.73
27506
6
90
$2,215.30
27507
6
90
$1,703.43
27508
4
90
$587.22
27509
4
90
$959.12
27510
4
90
$822.10
27511
5
90
$1,718.30
27513
5
90
$2,202.54
27514
5
90
$1,728.47 CPT Code SURG ANES FUD MAR
27516
4
90
$685.09
27517
4
90
$919.97
27519
5
90
$1,857.04
27520
3
90
$331.30
27524
4
90
$1,174.44
27530
3
90
$410.74
27532
3
90
$674.85
27535
4
90
$1,242.95
27536
4
90
$1,791.01
27538
3
90
$636.15
27540
4
90
$1,399.53
27550
0
90
$535.59
27552
3
90
$688.22
27556
4
90
$1,516.98
27557
4
90
$1,663.78
27558
4
90
$1,957.39
27560
0
90
$388.61
27562
3
90
$489.89
27566
4
90
$1,184.22
27570
3
10
$296.16
27580
4
90
$2,055.26
27590
5
90
$1,383.84
27591
5
90
$1,468.04
27592
5
90
$1,291.86
27594
5
90
$562.03
27596
5
90
$1,288.35
27598
5
90
$1,306.75
27599
4
0
BR
27600
3
90
$712.14
27601
3
90
$789.74
27602
3
90
$1,085.90
27603
3
90
$598.30
27604
3
90
$476.60
27605
3
10
$446.12
27606
3
10
$341.08
27607
3
90
$658.60
27610
3
90
$1,086.14
27612
3
90
$987.18
27613
3
10
$358.98
27614
3
90
$610.58
27615
3
90
$1,223.37
27616
3
90
$2,265.30
27618
3
90
$503.49
27619
3
90
$816.03
27620
3
90
$896.05 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
27625
3
90
$1,010.88
27626
3
90
$1,099.43
27630
3
90
$554.41
27632
3
90
$734.85
27634
3
90
$1,194.71
27635
3
90
$1,040.33
27637
3
90
$1,261.18
27638
3
90
$1,272.30
27640
3
90
$1,174.44
27641
3
90
$1,174.44
27645
4
90
$1,817.22
27646
4
90
$1,872.27
27647
4
90
$1,708.80
27648
3
0
$186.18
27650
5
90
$1,076.57
27652
5
90
$1,245.25
27654
5
90
$1,291.86
27656
3
90
$717.96
27658
3
90
$636.15
27659
3
90
$782.96
27664
3
90
$420.84
27665
3
90
$587.22
27675
3
90
$662.73
27676
3
90
$782.40
27680
3
90
$598.30
27681
3
90
$717.96
27685
3
90
$694.88
27686
3
90
$782.96
27687
5
90
$743.81
27690
3
90
$782.96
27691
3
90
$978.70
27692
#
3
0
$192.08
27695
3
90
$844.91
27696
3
90
$1,130.37
27698
3
90
$1,251.48
27700
3
90
$1,614.82
27702
7
90
$2,502.97
27703
7
90
$2,381.86
27704
3
90
$1,085.90
27705
4
90
$1,223.37
27707
4
90
$664.53
27709
4
90
$1,468.04
27712
4
90
$1,781.23
27715
4
90
$1,978.15
27720
3
90
$1,524.47 CPT Code SURG ANES FUD MAR
27722
3 90 $1,574.45 27724 3
90
$2,055.26
27725
3
90
$2,260.75
27726
3
90
$1,060.76
27727
3
90
$1,776.30
27730
3
90
$1,006.11
27732
3
90
$606.80
27734
3
90
$1,098.08
27740
3
90
$1,493.71
27742
4
90
$1,816.67
27745
3
90
$1,307.49
27750
3
90
$539.44
27752
3
90
$685.09
27756
3
90
$831.89
27758
3
90
$1,242.95
27759
4
90
$1,242.95
27760
3
90
$345.14
27762
3
90
$522.61
27766
3
90
$919.97
27767
3
90
$274.08
27768
3
90
$450.08
27769
4
90
$793.56
27780
3
90
$306.55
27781
3
90
$449.43
27784
3
90
$812.31
27786
3
90
$327.06
27788
3
90
$455.40
27792
3
90
$880.83
27808
3
90
$341.15
27810
3
90
$518.02
27814
3
90
$1,223.37
27816
3
90
$324.45
27818
3
90
$636.15
27822
3
90
$1,419.11
27823
3
90
$1,526.77
27824
3
90
$381.69
27825
3
90
$763.38
27826
3
90
$1,145.08
27827
3
90
$1,830.17
27828
3
90
$2,123.77
27829
3
90
$709.20
27830
0
90
$371.38
27831
3
90
$414.88
27832
3
90
$802.74
27840
0
90
$381.80 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
27842
3
90
$525.33
27846
3
90
$1,076.57
27848
3
90
$1,194.01
27860
3
10
$200.49
27870
3
90
$1,702.93
27871
3
90
$779.09
27880
4
90
$1,419.11
27881
4
90
$1,518.94
27882
4
90
$1,027.63
27884
4
90
$655.66
27886
4
90
$1,480.77
27888
4
90
$1,125.50
27889
4
90
$1,125.50
27892
3
90
$1,025.41
27893
3
90
$1,025.41
27894
3
90
$1,606.74
27899
3
0
BR
28001
3
10
$259.70
28002
3
10
$473.12
28003
3
90
$679.18
28005
3
90
$684.95
28008
3
90
$423.65
28010
3
90
$240.30
28011
3
90
$344.35
28020
3
90
$745.58
28022
3
90
$495.49
28024
3
90
$434.34
28035
3
90
$987.18
28039
3
90
$855.37
28041
3
90
$791.55
28043
3
90
$371.62
28045
3
90
$598.30
28046
3
90
$1,174.44
28047
3
90
$1,660.97
28050
3
90
$723.21
28052
3
90
$478.64
28054
3
90
$393.40
28055
3
90
$470.56
28060
3
90
$662.73
28062
3
90
$1,005.20
28070
3
90
$606.80
28072
3
90
$639.57
28080
3
90
$543.08
28086
3
90
$987.18
28088
3
90
$758.92 CPT Code SURG ANES FUD MAR
28090
3
90
$493.01
28092
3
90
$397.54
28100
3
90
$745.58
28102
3
90
$685.09
28103
3
90
$587.22
28104
3
90
$589.09
28106
3
90
$587.22
28107
3
90
$547.93
28108
3
90
$478.64
28110
3
90
$419.47
28111
3
90
$549.49
28112
3
90
$508.40
28113
3
90
$619.36
28114
3
90
$1,435.92
28116
3
90
$837.62
28118
3
90
$837.62
28119
3
90
$598.30
28120
3
90
$717.96
28122
3
90
$647.74
28124
3
90
$474.09
28126
3
90
$423.41
28130
3
90
$978.70
28140
3
90
$717.96
28150
3
90
$445.14
28153
3
90
$478.64
28160
3
90
$478.64
28171
4
90
$978.70
28173
4
90
$978.70
28175
4
90
$636.15
28190
3
10
$237.67
28192
3
90
$457.87
28193
3
90
$564.75
28200
3
90
$587.22
28202
3
90
$782.96
28208
3
90
$579.81
28210
3
90
$574.30
28220
3
90
$598.30
28222
3
90
$717.96
28225
3
90
$363.13
28226
3
90
$472.31
28230
3
90
$405.17
28232
3
90
$356.37
28234
3
90
$509.50
28238
3
90
$828.41
28240
3
90
$452.04 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
28250
3
90
$717.96
28260
3
90
$1,089.27
28261
3
90
$1,279.44
28262
3
90
$1,957.39
28264
3
90
$1,184.22
28270
3
90
$611.56
28272
3
90
$362.27
28280
3
90
$518.50
28285
3
90
$570.69
28286
3
90
$570.69
28288
3
90
$590.77
28289
3
90
$684.03
28290
3
90
$636.15
28292
3
90
$805.56
28293
3
90
$956.20
28294
3
90
$929.76
28296
3
90
$1,222.40
28297
3
90
$929.76
28298
3
90
$750.76
28299
3
90
$1,223.37
28300
3
90
$939.55
28302
3
90
$880.83
28304
3
90
$847.06
28305
3
90
$978.70
28306
3
90
$704.66
28307
3
90
$802.53
28308
3
90
$567.36
28309
3
90
$974.71
28310
3
90
$508.76
28312
3
90
$625.07
28313
3
90
$658.70
28315
3
90
$445.14
28320
3
90
$782.96
28322
3
90
$799.66
28340
3
90
$949.34
28341
3
90
$1,139.20
28344
3
90
$587.22
28345
3
90
$782.96
28360
3
90
$1,110.94
28400
3
90
$265.40
28405
3
90
$430.46
28406
3
90
$592.87
28415
3
90
$1,317.57
28420
3
90
$1,390.74
28430
3
90
$264.25 CPT Code SURG ANES FUD MAR
28435
3
90
$362.12
28436
3
90
$472.26
28445
3
90
$1,246.19
28446
3
90
$1,367.63
28450
3
90
$254.46
28455
3
90
$314.97
28456
3
90
$381.69
28465
3
90
$633.86
28470
3
90
$266.94
28475
3
90
$303.76
28476
3
90
$386.59
28485
3
90
$607.84
28490
3
90
$137.66
28495
3
90
$168.76
28496
3
90
$443.08
28505
3
90
$845.35
28510
3
90
$117.64
28515
3
90
$151.09
28525
3
90
$715.71
28530
3
90
$197.44
28531
3
90
$404.14
28540
0
90
$343.37
28545
3
90
$461.59
28546
3
90
$662.73
28555
3
90
$861.17
28570
0
90
$282.78
28575
3
90
$469.44
28576
3
90
$624.99
28585
3
90
$1,003.59
28600
0
90
$239.32
28605
3
90
$312.96
28606
3
90
$445.92
28615
3
90
$754.63
28630
0
10
$211.71
28635
3
10
$302.98
28636
3
10
$381.69
28645
3
90
$806.91
28660
0
10
$145.98
28665
3
10
$258.93
28666
3
10
$344.76
28675
3
90
$730.88
28705
3
90
$1,761.65
28715
3
90
$1,468.04
28725
3
90
$1,174.44
28730
3
90
$1,076.57 Oklahoma Workers= Compensation Court Schedule of Medical and Hospital Fees Effective 01/01/12
CPT® only copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS
restrictions apply to government use.
Surgery
CPT
Code
SURG
ANES
FUD
MAR
28735
3
90
$1,363.30
28737
3
90
$1,174.44
28740
3
90
$924.33
28750
3
90
$860.46
28755
3
90
$514.80
28760
3
90
$728.44
28800
3
90
$991.67
28805
3
90
$1,027.63
28810
3
90
$567.64
28820
3
90
$533.18
28825
3
90
$736.78
28890
3
90
$402.39
28899
3
0
BR
29000
3
0
$474.67
29010
3
0
$313.19
29015
3
0
$371.64
29020
3
0
$313.19
29025
3
0
$381.69
29035
3
0
$238.78
29040
3
0
$274.03
29044
3
0
$271.65
29046
3
0
$257.54
29049
4
0
$127.23
29055
4
0
$214.50
29058
4
0
$128.45
29065
3
0
$99.06
29075
3
0
$91.01
29085
3
0
$96.80
29086
3
0
$78.29
29105
3
0
$92.38
29125
3
0
$71.01
29126
3
0
$127.23
29130
3
0
$48.93
29131
3
0
$104.96
29200
3
0
$59.43
29240
4
0
$67.57
29260
3
0
$56.04
29280
3
0
$55.99
29305
3
0
$240.96
29325
3
0
$263.57
29345
3
0
$143.77
29355
3
0
$148.09
29358
3
0
$157.78
29365
3
0
$128.58
29405
3
0
$94.03 CPT Code SURG ANES FUD MAR
29425
3
0
$103.83
29435
3
0
$146.80
29440
3
0