Community Question
From time to time, we like to take a question we get from our extended workers’ compensation family and turn it over to the human-powered Simply Research Compliance Team as well as our favorite artificial intelligence tool(s).
Here’s what we got when we got a question about disposable hyperbaric oxygen chambers.
Question from the Community: What is the best way to determine what the fee schedule is for code A4575 by state and then a way to determine which states are red (no variation from fee schedule), yellow (does offer variation from fee schedule sometimes), or green (no stipulations on varying from fee schedule pricing)?
What we got when we asked Team SR:
This is what we provide for fee schedules
https://www.workcompresearch.com/members/reference_desk.php?state=
It will take you to the fee schedule for the state (if applicable). Some states charge for this.
Also under Billing and Payments under medical section in our Compliance Summaries, if there is anything that the rule or statute address differently that would be in there. For example, here’s what we have for the State of Washington:
Medical Fee Schedule 51.04.030 51.36.080 51.36.085
The director and interested persons will establish and, at his or her discretion, periodically change as necessary, and make available a fee schedule of the maximum charges to be made by any physician, hospital or medical provider. The department will coordinate with other state purchasers of health care services to establish as much consistency and uniformity in billing and coding practices as possible, taking into consideration the unique requirements and differences between programs. No services provided to injured workers, whether aliens or other injured workers, who are not residing in the United States at the time of receiving the services, shall be charged or paid at a rate or rates exceeding those specified in the fee schedule, and no contract providing for greater fees shall be valid as to the overcharge.
All fees and medical charges must conform to the fee schedule established by the director and must be paid within sixty days of receipt by the department of a proper billing in the form prescribed by department rule or sixty days after the claim is allowed by final order or judgment.
What we got when we asked AI (remember from the CQ that red=no variation from fee schedule, yellow=does offer variation from fee schedule sometimes, and green=no stipulations on varying from fee schedule pricing):
StateStatusWhy (one‑liner)Key Authority / SourceAlabama🟥State publishes WC fee schedules (incl. DME Fee Schedule) and DME policy in the Admin Code. [labor.alabama.gov], [admincode….tate.al.us]ADOL – 2025 Fee Schedules; Ala. Admin. Code 480‑5‑5‑.32 DMEAlaska🟥Official WC Medical Fee Schedule governs reimbursement; current editions posted by the Division. [labor.alabama.gov], [admincode….tate.al.us]AK WC – Medical Fee Schedule; 2025 AK MFS (PDF)Arizona🟥ICA maintains physician/pharmaceutical fee schedule; 2025 law broadened scope to health/dental/supply providers. [labor.alaska.gov], [labor.alaska.gov]ICA Fee Schedule hub; SB 1551 summaryArkansas🟥AWCC Rule 30 adopts a Medicare‑based Medical Fee Schedule (includes HCPCS/DME). [labor.alaska.gov], [labor.alaska.gov]AWCC – Medical Fee Schedule; Rules/Advisories/MFSCalifornia🟥OMFS controls all services; DMEPOS paid at 120% of Medicare per 8 CCR §9789.60. [azica.gov], [azleg.gov]CA DWC – OMFS; 8 CCR §9789.60 (DMEPOS)Colorado🟥Rule 18 (7 CCR 1101‑3) sets max fees & payment policies across services. [azica.gov], [azleg.gov]CDLE – Rule 18 page; 7 CCR 1101‑3 Rule 18Connecticut🟨Practitioner FS + Hospital/ASC FS in force; fee publications via Optum/State memos. [labor.arkansas.gov], [labor.arkansas.gov]CT WCC – Fee schedules; CT WC Fee Schedule FAQ (Optum/Medata)Delaware🟥HCPS fee schedule governs max reimbursements (with Instructions & Guidelines). [labor.arkansas.gov]DE OWC – Health Care Payment System/Fee ScheduleFlorida🟥Reimbursement Manuals (providers, hospitals, ASCs) under 69L‑7 set WC maximums. [labor.arkansas.gov], [dir.ca.gov]DFS – Reimbursement Manuals; FAC 69L‑7 indexGeorgia🟥SBWC Medical & Dental Fee Schedules (Fair Health) govern payments. [regulation…justia.com], [dir.ca.gov]GA SBWC – Fee Schedules; GA Fee Schedule FAQHawaii🟥HAR 12‑15 Workers’ Comp Medical Fee Schedule + Exhibit A supplement (Medicare‑based). [regulation…justia.com], [cdle.colorado.gov]HAR 12‑15 MFS (PDF); Exhibit A – Supplemental MFSIdaho🟥IDAPA 17.01.01.803 and the Commission’s Medical Fee Schedule resources control payment. [sos.state.co.us], [cdle.colorado.gov]IIC – Medical Fee Schedule; IDAPA 17.01.01 (PDF)Illinois🟥IWCC Medical Fee Schedule sets MRAs across categories (professional & facilities). [sos.state.co.us], [portal.ct.gov]IWCC Schedule Portal; 50 Ill. Adm. Code 9110.90Indiana🟨Hospitals/ASCs capped at 200% of Medicare; other providers paid at 80th percentile UCR. [toolbox.medata.com], [portal.ct.gov]ICRB – Fee Schedule summary; IN WCB – Providers guidanceIowa🟩No state MFS—law requires insurers to pay “reasonable and necessary” medical charges; agency confirms no WC fee schedule. [toolbox.medata.com], [dowc.refmed.com]Iowa DWC email confirming no fee schedule; daisyBill Iowa billing guideKansas🟥Schedule of Medical Fees (biannual) controls reimbursement; online code lookup/QRT available. [dowc.refmed.com], [myfloridacfo.com]KDOL – Medical Services & Fee Schedule; Code/QRT searchKentucky🟥Physician FS (803 KAR 25:089) + Hospital/ASC cost‑to‑charge schedule (803 KAR 25:091). [flrules.org], [myfloridacfo.com]KY DWC – Medical Services; 803 KAR 25:091Louisiana🟥Statute directs OWCA to maintain a reimbursement schedule for drugs/supplies and medical services. [flrules.org], [sbwc.georgia.gov]La. R.S. 23:1034.2; LA Works – OWC resourcesMaine🟥Board Rule Ch. 5 Medical Fee Schedule (RBRVS/DRG/APC methodology) governs all services. [toolbox.medata.com], [sbwc.georgia.gov]ME WCB – Medical Fee Schedules; 39‑A M.R.S. §209‑AMaryland🟥COMAR 14.09.08 Medical Fee Guide sets MRAs; (note: Rx/DME not separately valued in guide). [toolbox.medata.com], [labor.hawaii.gov]COMAR 14.09.08; MFG Misc. Info (DME note)Massachusetts🟥114.3 CMR 40.00 controls WC rates, including Durable Medical Equipment. [regulation…justia.com], [labor.hawaii.gov]Mass.gov – 114.3 CMR 40.00; §40.03 (lists DME)Michigan🟥Workers’ Comp Health Care Services rules (R 418) + WDCA fee schedule/manual posted by LEO. [regulation…justia.com], [iic.idaho.gov]LEO – HCS Rules/Manuals/Fees; 2023 HCS Rule Set (R 418…)Minnesota🟥DLI medical fee schedules (RBRVS/HOFS/ASCPS); rules incorporate Medicare RVUs and DLI instructions. [proddfmmai…indows.net], [iic.idaho.gov]MN DLI – Fee schedules; Minn. R. 5221.4005Mississippi🟥MWCC Medical Fee Schedule (comprehensive rules + facility schedules). [proddfmmai…indows.net], [iwcc.refmed.com]Miss. Admin. Code – Part 2 MFS; MWCC MFS (11/15/2022 ed.)Missouri🟩No statewide MFS—charges must be fair & reasonable; disputes handled under 8 CSR 50‑2.030. [ilga.gov], [iwcc.refmed.com]MO DOLIR – Medical Fee Disputes; TherapyComply – MO (no MFS)Montana🟥DLI facility and professional fee schedules; DME priced per ARM 24.29.1523 if no RVU. [ilga.gov], [icrb.net]ARM 24.29.1433 – Facility rules; ARM 24.29.1523 – DMENebraska🟥Workers’ Compensation Court publishes Medical Services, Hospital/ASC, and Implantable Device fee schedules. [in.gov], [icrb.net]NE WCC – Fee Schedules; NE WCC News – 2025 schedulesNevada🟥Nevada Medical Fee Schedule (NRS 616C.260): annual CPI‑based updates; conversion factors by code set. [in.gov], [s3.amazonaws.com]DIR – 2024/2025 MFS (PDF); DIR WCS – 2026 MFS linkNew Hampshire🟩No WC MFS—statute provides “reasonable” medical care framework; prior efforts to enact a schedule failed. [kb.daisybill.com], [s3.amazonaws.com], [kb.daisybill.com]RSA 281‑A:23; TherapyComply – NH (no MFS); NHBR – fee schedule rejected
New Jersey🟩No WC medical fee schedule; statute pays reasonable & customary and disputes are adjudicated by the Division under N.J.S.A. 34:15‑15. [does.dc.gov], [s3.amazonaws.com]N.J.S.A. 34:15‑15 (Justia); NJ WC Law booklet (DOL)New Mexico🟥WCA Health Care Provider (HCP) Fee Schedule sets maximum charges; providers paid the lesser of U&C or the schedule. [does.dc.gov], [s3.amazonaws.com]2026 HCP Fee Schedule & Billing Instructions (WCA); NMSA §52‑4‑5New York🟥Stand‑alone DME Fee Schedule (12 NYCRR Part 442); PAR via OnBoard for items not listed. [labor.arkansas.gov], [legalclarity.org]NY WCB DME Fee Schedule page; 12 NYCRR §442.2North Carolina🟥NCIC MFS: DME = 100% CMS DMEPOS; if no fee, invoice +20% per Section 15. [labor.arkansas.gov], [legalclarity.org]11 NCAC 23J .0102(f); NCIC Fee Schedule §15 (DME/Supplies)North Dakota🟥WSI DME fee schedule (e.g., policy baseline 120% of Medicare) with annual updates. [labor.state.ak.us], [labor.alaska.gov]WSI 2025 update (120% of Medicare for DME); WSI Fee Schedules pageOhio🟥BWC maintains comprehensive fee schedules (PPMS, facility) used system‑wide. [labor.state.ak.us]Ohio BWC – Find a fee scheduleOklahoma🟥WCC Medical Fee Schedule + ground rules govern WC medical/DME. [labor.alaska.gov], [wotc.alabama.gov]OK WCC – Medical (MFS); 2024 WCC MFS PDFOregon🟥OAR 436‑009 medical fee rules with DMEPOS rule 436‑009‑0080 and Appendix E amounts. [regulation…justia.com], [wotc.alabama.gov]OAR 436‑009 (Medical Fee & Payment Rules); OAR 436‑009‑0080 (DMEPOS)Pennsylvania🟥WC fee schedule capped to Medicare; if no Medicare allowance, pay 80% of U&C or actual, whichever lower. [regulation…justia.com]PA WC Part B notes (34 Pa. Code §127.103(c))Rhode Island🟥DLT publishes a WC medical fee schedule (maintained by Rising Medical Solutions) covering HCPCS/DME. 1718RI DLT – Medical Fees & Hospital Rates; Rising – RI WC MFS (2026)South Carolina🟥Medical Services Provider Manual (MSPM) sets MAPs; separate hospital/ASC manual follows Medicare‑based methods. [provider.i…dicaid.com]SC WCC – Medical Fee Schedules (MSPM)South Dakota🟥ARSD 47:03:05 governs WC medical reimbursement (RVUs, criteria, disputes). [mydss.mo.gov]SD DLR – Workers’ Comp (Medical Fee Schedules)Tennessee🟥Medicare‑based MFS; if no Medicare methodology/price, max = U&C (80% of billed) under rule. [cgsmedicare.com]TN Bureau WC – Medical Fee Schedule pageTexas🟥28 TAC Ch. 134 fee guidelines; Labor Code §408.0284 governs DME reimbursement (guideline or contract). [cgsmedicare.com], [dir.ca.gov]TDI‑DWC – Fee guideline hub; Tex. Labor Code §408.0284 (DME)Utah🟥Annual Medical Fee Standards under Rule R612‑300 (CPT/RBRVS + conversion factors) control DME fees. [labor.state.ak.us], [blog.daisybill.com]Utah 2026 Medical Fee Standard; R612‑300 (Medical Care rules)Vermont🟥Rule 40 WC Medical Fee Schedule caps employer liability at maximum fees; 2026 update in process. [dir.ca.gov], [blog.daisybill.com]VT Rule 40 (CFR‑style view); VT DOL – Rule 40 & 2026 draftVirginia🟥Commission Medical Fee Schedule + ground rules; updates published (e.g., 2024 tables; 2026 changes). [evans-dixon.com], [in.gov], [evans-dixon.com]VWC – Medical Fee Schedules; 2024 MFS PDF; 2026 Summary of ChangesWashington🟥L&I MARFS publishes payment policies + maximum fees with DME chapter and fee lookup tools. [in.gov]WA L&I – MARFS fee schedules & policiesWest Virginia🟥OIC schedule typically Medicare +35%; if no Medicare, max set via reasonable & customary under OIC methodology. [ecfr.gov]WV OIC – Medical Reimbursement (methodology)Wisconsin🟩No statewide WC MFS at present; law mandates a hospital‑only fee schedule effective by July 1, 2027 (not yet active).[M3 – WI Hospital FS law summary]; [Lindner & Marsack – statute synopsis]Wyoming🟥Chapter 9 fee schedules adopt RBRVS, NCCI edits, and state conversion factors; routine bulletins update fees.[WY Admin. Code Ch.9 §9‑2 (RBRVS/NCCI)]; [WY DWS Provider Bulletins]
Notes on A4575 (Topical hyperbaric oxygen chamber, disposable)
- In fee schedule states (🟥), A4575 follows the state’s governing methodology (e.g., listed max fee; administrative pricing if unlisted; CMS‑based formulas or invoice pricing rules like invoice +20% in NC). [legalclarity.org], [regulation…justia.com], [wotc.alabama.gov]
- In Pennsylvania, if there’s no Medicare allowance, the regulation pays 80% of U&C or actual charge, whichever is lower. [regulation…justia.com]
- In New York, if the item is not on the DME Fee Schedule, the supplier must obtain a PAR in OnBoard before furnishing. [labor.arkansas.gov]
- In New Jersey (🟩), reimbursement is reasonable & customary under N.J.S.A. 34:15‑15, adjudicated by the Division if contested. [does.dc.gov]
- In Wisconsin (🟩 for now), there is no WC MFS for DME today; the hospital schedule will begin by 7/1/2027 and will apply to hospital charges only.
- Where a DME code has no listed max (e.g., MT ARM 24.29.1523 invoice+markup rule; CA DMEPOS at 120% of Medicare), payers follow the state‑specific fallback (invoice+% / U&C) or the Medicare‑based method the rule adopts. [sos.ms.gov], [labor.arkansas.gov]No‑FS states (🟩) pay reasonable/UCR amounts subject to dispute processes (e.g., IA & MO administrative procedures). [iwcc.refmed.com], [dli.mn.gov]
