78673965.2-605Virginia Decodedhttps://vacode.org2016Workers' CompensationNotice Of Accident; Filing Claims; Medical Attention And ExaminationLiability of employer for medical services ordered by Commission; fee schedules for medical services; malpractice; assistants-at-surgery; codingCode 1950, § 65-86; 1968, c. 660, § 65.1-89; 1991, c. 355; 2014, c. 670; 2015, c. 456; 2016, cc. 279, 290.Stephen J. Leibovic, MD v. San Juanito Melchor,etc07900022001-03-06https://www.courtlistener.com/opinion/1065195/stephen-j-leibovic-md-v-san-juanito-melchoretc/ . . . that the . . . <abbr title="Court of Appeals">COA</abbr> . . . Fredericksburg Orthopaedic Associates v. Fredericksburg . . . 17141222013-05-14https://www.courtlistener.com/opinion/1061407/fredericksburg-orthopaedic-associates-v-fredericks/ . . . compensation patients is . . . <abbr title="Court of Appeals">COA</abbr>NAT. LINEN SER./NAT. SERVICE v. Parker1523941461 S.E.2d 4041995-09-05https://www.courtlistener.com/opinion/1068267/nat-linen-sernat-service-v-parker/ . . . for by the injured person? (Code of Virginia, § 65.2-605) . . . <abbr title="Court of Appeals">COA</abbr>CERES MARINE TERMINALS v. Armstrong1603112722 S.E.2d 3012012-03-06https://www.courtlistener.com/opinion/1061735/ceres-marine-terminals-v-armstrong/ . . . treatment for the injury. However, under Code § 65.2-605, "[t]he pecuniary liability of the . . . <abbr title="Court of Appeals">COA</abbr>Town & Country Hospital, LP v. Reginald Davis19381442015-04-21https://www.courtlistener.com/opinion/2795264/town-country-hospital-lp-v-reginald-davis/ . . . but located outside . . . <abbr title="Court of Appeals">COA</abbr>Miller v. POTOMAC HOSP. FOUNDATION0751072653 S.E.2d 5922007-12-11https://www.courtlistener.com/opinion/1062910/miller-v-potomac-hosp-foundation/ . . . 's medical bills in accordance with Code § 65.2-605 by failing to raise such defense to the . . . <abbr title="Court of Appeals">COA</abbr>Amoco Foam Products Company v. Essie L. Johnson03249741997-12-30https://www.courtlistener.com/opinion/1067190/amoco-foam-products-company-v-essie-l-johnson/ . . . original industrial injury"). See also Code . . . <abbr title="Court of Appeals">COA</abbr> . . . Virginia Polytechnic Institute & State . . . 09430532005-12-13https://www.courtlistener.com/opinion/1063336/virginia-polytechnic-institute-state-universitycom/ . . . treatment is paid for by the injured person.” Code § 65.2-605. Whenever an employee . . . <abbr title="Court of Appeals">COA</abbr> . . . Julio Emilio Posada v. Virginia Polytechnic Institute & . . . 09540532005-12-13https://www.courtlistener.com/opinion/1063344/julio-emilio-posada-v-virginia-polytechnic-institu/ . . . treatment is paid for by the injured person.” Code § 65.2-605. Whenever an employee . . . <abbr title="Court of Appeals">COA</abbr>Stephen J. Leibovic, MD v. San Juanito Melchor,etc07900022001-03-06https://www.courtlistener.com/opinion/1065195/stephen-j-leibovic-md-v-san-juanito-melchoretc/ . . . that the . . . <abbr title="Court of Appeals">COA</abbr> . . . Fredericksburg Orthopaedic Associates v. Fredericksburg . . . 17141222013-05-14https://www.courtlistener.com/opinion/1061407/fredericksburg-orthopaedic-associates-v-fredericks/ . . . compensation patients is . . . <abbr title="Court of Appeals">COA</abbr>NAT. LINEN SER./NAT. SERVICE v. Parker1523941461 S.E.2d 4041995-09-05https://www.courtlistener.com/opinion/1068267/nat-linen-sernat-service-v-parker/ . . . for by the injured person? (Code of Virginia, § 65.2-605) . . . <abbr title="Court of Appeals">COA</abbr>CERES MARINE TERMINALS v. Armstrong1603112722 S.E.2d 3012012-03-06https://www.courtlistener.com/opinion/1061735/ceres-marine-terminals-v-armstrong/ . . . treatment for the injury. However, under Code § 65.2-605, "[t]he pecuniary liability of the . . . <abbr title="Court of Appeals">COA</abbr>Town & Country Hospital, LP v. Reginald Davis19381442015-04-21https://www.courtlistener.com/opinion/2795264/town-country-hospital-lp-v-reginald-davis/ . . . but located outside . . . <abbr title="Court of Appeals">COA</abbr>Miller v. POTOMAC HOSP. FOUNDATION0751072653 S.E.2d 5922007-12-11https://www.courtlistener.com/opinion/1062910/miller-v-potomac-hosp-foundation/ . . . 's medical bills in accordance with Code § 65.2-605 by failing to raise such defense to the . . . <abbr title="Court of Appeals">COA</abbr>Amoco Foam Products Company v. Essie L. Johnson03249741997-12-30https://www.courtlistener.com/opinion/1067190/amoco-foam-products-company-v-essie-l-johnson/ . . . original industrial injury"). See also Code . . . <abbr title="Court of Appeals">COA</abbr> . . . Virginia Polytechnic Institute & State . . . 09430532005-12-13https://www.courtlistener.com/opinion/1063336/virginia-polytechnic-institute-state-universitycom/ . . . treatment is paid for by the injured person.” Code § 65.2-605. Whenever an employee . . . <abbr title="Court of Appeals">COA</abbr> . . . Julio Emilio Posada v. Virginia Polytechnic Institute & . . . 09540532005-12-13https://www.courtlistener.com/opinion/1063344/julio-emilio-posada-v-virginia-polytechnic-institu/ . . . treatment is paid for by the injured person.” Code § 65.2-605. Whenever an employee . . . <abbr title="Court of Appeals">COA</abbr>http://law.lis.virginia.gov/vacode/65.2-605/2.2-3700Short title; policy/2.2-3700/2.2-4300Short title; purpose; declaration of intent/2.2-4300/65.2-603Duty to furnish medical attention, etc., and vocational rehabilitation; effect of refusal of employee to accept/65.2-603//65.2-605/65.2/6/65.2-60565.2-605.165.2-821.1 Physicians exclusive of surgeons;sectionA1A12 Type One teaching hospitals;sectionA3A32 Hospitals, exclusive of Type One teaching hospitals;sectionA4A42 Ambulatory surgical centers;sectionA5A52 Providers of outpatient medical services not covered by subdivision 1, 2, or 5; andsectionA6A62 Northern region, consisting of the area for which three-digit ZIP code prefixes 201 and 220 through 223 have been assigned by the U.S. Postal Service.sectionA71A713 Northwest region, consisting of the area for which three-digit ZIP code prefixes 224 through 229 have been assigned by the U.S. Postal Service.sectionA72A723 Central region, consisting of the area for which three-digit ZIP code prefixes 230, 231, 232, 238, and 239 have been assigned by the U.S. Postal Service.sectionA73A733 Eastern region, consisting of the area for which three-digit ZIP code prefixes 233 through 237 have been assigned by the U.S. Postal Service.sectionA74A743 Near Southwest region, consisting of the area for which three-digit ZIP code prefixes 240, 241, 244, and 245 have been assigned by the U.S. Postal Service.sectionA75A753The pecuniary liability of the employer for a:sectionBB1 Medical, surgical, and hospital service herein required when ordered by the Commission that is provided to an injured person prior to the transition date, regardless of the date of injury, shall be limited absent a contract providing otherwise, to such charges as prevail in the same community for similar treatment when such treatment is paid for by the injured person;sectionB1B12 Fee scheduled medical service provided on or after the transition date, regardless of the date of injury, shall be limited to:
sectionB2B22 The amount provided for the payment for the fee scheduled medical service as set forth in a contract under which the provider has agreed to accept a specified amount in payment for the service provided, which amount may be less than or exceed the maximum amount for the service as set forth in the applicable Virginia fee schedule;sectionB2aB2a3 In the absence of a contract described in subdivision 2 a, the lesser of the billing amount or the amount for the fee scheduled medical service as set forth in the applicable Virginia fee schedule that is in effect on the date the service is provided, subject to an increase approved by the Commission pursuant to subsection H; orsectionB2bB2b3 In the absence of (i) a contract described in subdivision 2 a and (ii) a provision in a Virginia fee schedule that sets forth a maximum amount for the medical service on the date it is provided, the maximum amount determined by the Commission as provided in subsection E; andsectionB2cB2c3 Medical service provided on or after the transition date in the treatment of a traumatic injury or serious burn, regardless of the date of injury, shall be limited to:
sectionB3B32 The amount provided for the payment for the medical service provided for the treatment of the traumatic injury or serious burn as set forth in a contract under which the provider has agreed to accept a specified amount in payment for the service provided, which amount may be less than or exceed the maximum amount for the service calculated pursuant to subdivision 3 b; orsectionB3aB3a3The Commission shall adopt regulations establishing initial Virginia fee schedules for fee scheduled medical services as follows:sectionCC1 Separate initial Virginia fee schedules shall be established for fee scheduled medical services (i) provided by each category of providers of fee scheduled medical services and (ii) within each of the medical communities to reflect the variations among the medical communities as provided in subdivision 3, for each category of providers of fee scheduled medical services.sectionC2C22 The Virginia fee schedules for each medical community shall reflect variations among medical communities in (i) all reimbursements and other amounts paid to providers for fee scheduled medical services among the medical communities and (ii) the extent to which the number of providers within the various medical communities is adequate to meet the needs of injured workers.sectionC3C32The Commission shall review Virginia fee schedules during the year that follows the transition date and biennially thereafter and, if necessary, adjust the Virginia fee schedules in order to address (i) inflation or deflation as reflected in the medical care component of the Consumer Price Index for All Urban Consumers (CPI-U) for the South as published by the Bureau of Labor Statistics of the U.S. Department of Labor; (ii) access to fee scheduled medical services; (iii) errors in calculations made in preparing the Virginia fee schedules; and (iv) incentives for providers. The Commission shall not adjust a Virginia fee schedule in a manner that reduces fees on an existing schedule unless such a reduction is based on deflation or a finding by the Commission that advances in technology or errors in calculations made in preparing the Virginia fee schedules justify a reduction in fees.sectionDD1The Commission shall:sectionFF1 Utilize a 10-member regulatory advisory panel to assist in the development of regulations adopting initial Virginia fee schedules pursuant to subsection C and in adjusting initial Virginia fee schedules pursuant to subsection D. One member of the regulatory advisory panel shall be selected by the Commission from each of the following: (i) the American Insurance Association; (ii) the Property and Casualty Insurers Association of America; (iii) the Virginia Self-Insurers Association, Inc.; (iv) the Medical Society of Virginia; (v) the Virginia Hospital and Healthcare Association; (vi) a Type One teaching hospital; (vii) the Virginia Orthopaedic Society; (viii) the Virginia Trial Lawyers Association; (ix) a group self-insurance association representing employers; and (x) a local government group self-insurance pool formed under Chapter 27 (§ 15.2-2700 et seq.) of Title 15.2. The Commission shall meet with the regulatory advisory panel and consider the recommendations of its members in its development of the Virginia fee schedules pursuant to subsections C and D.sectionF2F22No provider shall use a different charge master or schedule of fees for any medical service provided under this title than the provider uses for health care services provided to patients who are not claimants under this title.sectionII1The employer shall not be liable in damages for malpractice by a physician or surgeon furnished by him pursuant to the provisions of § 65.2-603, but the consequences of any such malpractice shall be deemed part of the injury resulting from the accident and shall be compensated for as such.sectionJJ1The Commission shall determine the number and geographic area of communities across the Commonwealth. In establishing the communities, the Commission shall consider the ability to obtain relevant data based on geographic area and such other criteria as are consistent with the purposes of this title. The Commission shall use the communities established pursuant to this subsection in determining charges that prevail in the same community for treatment provided prior to the transition date.sectionKK1The pecuniary liability of the employer for treatment of a medical service that is rendered on or after July 1, 2014, by:sectionLL1 A nurse practitioner or physician assistant serving as an assistant-at-surgery shall be limited to no more than 20 percent of the reimbursement due to the physician performing the surgery; andsectionL1L12 An assistant surgeon in the same specialty as the primary surgeon shall be limited to no more than 50 percent of the reimbursement due to the primary physician performing the surgery.sectionL2L22Multiple procedures completed on a single surgical site associated with a medical service rendered on or after July 1, 2014, shall be coded and billed with appropriate CPT codes and modifiers and paid according to the National Correct Coding Initiative rules and the CPT codes as in effect at the time the health care was provided to the claimant.sectionMM1