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EXHIBIT AChapters 12-15Hawaii Administrative RulesWORKERS’ COMPENSATION SUPPLEMENTALMEDICAL FEE SCHEDULEJanuary 1, 2014The codes in the Workers’ Compensation Supplemental Medical Fee Schedule are obtained fromthe American Medical Association, the American Dental Association or the State Department ofLabor and Industrial Relations.The five character codes included in the Workers’ Compensation Supplemental Medical FeeSchedule are obtained from Current Procedural Terminology (CPT ), copyright 2013 by theAmerican Medical Association (AMA). CPT is developed by the AMA as a listing of descriptiveterms and five character identifying codes and modifiers for reporting medical services andprocedures performed by physicians.The responsibility for the content of the Workers’ Compensation Supplemental Medical FeeSchedule is with DLIR and no endorsement by the AMA is intended or should be implied. TheAMA disclaims responsibility for any consequences or liability attributable or related to any use,nonuse or interpretation of information contained in the Workers’ Compensation SupplementalMedical Fee Schedule. Fee schedules, relative value units, conversion factors and/or relatedcomponents are not assigned by the AMA, are not part of CPT, and the AMA is notrecommending their use. The AMA does not directly or indirectly practice medicine or dispensemedical services. The AMA assumes no liability for data contained or not contained herein. Anyuse of CPT outside of the Workers’ Compensation Supplemental Medical Fee Schedule shouldrefer to the most current CPT codes and descriptive terms. Applicable FARS/DFARS apply.CPT is a registered trademark of the American Medical AssociationThe five character codes starting with the letter “D” included in the Workers’ CompensationSupplemental Medical Fee Schedule are obtained from Current Dental Terminology 2013,copyright 2012 by the American Dental Association (ADA). CDT is developed by the ADA toachieve uniformity, consistency and accurate reporting of dental treatment.The calculated “value of one unit” is 33.54. The fee for each procedure should becomputed by multiplying its “unit value” by 33.54.A-1
TABLE OF CONTENTSTITLESURGERYIntegumentary SystemMusculoskeletal SystemRespiratory SystemCardiovascular SystemDigestive SystemNervous SystemEye and Ocular AdnexaAuditory SystemOperating 2953-9372493980, , 9657197001-977609894099070, 99080A-10A-10A-11A-11A-11DENTAL csProsthodontics, RemovableProsthodontics, FixedOral and Maxillofacial SurgeryAdjunctive General 11A-12A-12A-12A-12A-12EVALUATION AND MANAGEMENTOffice or Other Outpatient ServicesHospital Inpatient ServicesEmergency Department ServicesSpecial Evaluation and Management Services99201-992159923299281-9928599456A, 99456BA-12A-12A-13A-13RADIOLOGYDiagnostic Radiology (Diagnostic Imaging)Diagnostic UltrasoundRadiation OncologyNuclear MedicineMEDICINEVaccines, pecial Otorhinolaryngologic ServicesCardiovascularNoninvasive Vascular Diagnostic StudiesPulmonaryAllergy and Clinical ImmunologyNeurology and Neuromuscular ProceduresCentral Nervous System Assessments/TestsHydration, Therapeutic, Prophylactic, DiagnosticInjections and Infusions, and Chemotherapy andOther Highly Complex Drug or Highly ComplexBiologic Agent AdministrationPhotodynamic TherapyPhysical Medicine and RehabilitationChiropractic Manipulative TreatmentSpecial Services, Procedures and ReportsA-2
low-upDays205532.5SURGERYIntegumentary 5.015.324.46.916.618.3Follow-upDaysMusculoskeletal .42.2UnitCode DescriptionValue20560* Acupuncture, initial 15 minutes (inclusive of evaluation and supplies) . 1.020561*each additional 15 minutes . .151.951.366.774.316.553.669.5Follow-upDaysCPT only copyright 2013 American Medical Association. CDT copyright 2013 American Dental Association. All Rights Reserved. ApplicableFARS/DFARS Restrictions Apply to Government Use.A-3
w-upDaysCPT only copyright 2013 American Medical Association. CDT copyright 2013 American Dental Association. All Rights Reserved. ApplicableFARS/DFARS Restrictions Apply to Government Use.A-4
4.324.1Follow-upDaysRespiratory 11.312.2Cardiovascular System352073641027.60.736600372021.214.1Digestive System406544537826.114.7495054952018.222.2Nervous 5.95.33.74.410.3CPT only copyright 2013 American Medical Association. CDT copyright 2013 American Dental Association. All Rights Reserved. ApplicableFARS/DFARS Restrictions Apply to Government Use.A-5
7.6Follow-upDaysEye and Ocular .350.566.034.7Auditory System69005692009.55.769210694332.28.8Operating Microscope699908.2RADIOLOGYFees include both the technical and professional components. In the absence of any prior agreement, theprofessional component shall be thirty-five percent of the scheduled fee.Diagnostic Radiology (Diagnostic 82.11.72.01.72.43.12.2CPT only copyright 2013 American Medical Association. CDT copyright 2013 American Dental Association. All Rights Reserved. ApplicableFARS/DFARS Restrictions Apply to Government Use.A-6
aysCPT only copyright 2013 American Medical Association. CDT copyright 2013 American Dental Association. All Rights Reserved. ApplicableFARS/DFARS Restrictions Apply to Government Use.A-7
sDiagnostic 683176856768704.45.64.55.35.05.05.05.0Radiation 97.6Nuclear 7.411.216.315.49.47.48.68.2CPT only copyright 2013 American Medical Association. CDT copyright 2013 American Dental Association. All Rights Reserved. ApplicableFARS/DFARS Restrictions Apply to Government Use.A-8
ysCodeUnitValueFollow-upDaysMEDICINEFees include both the technical and professional components. In the absence of any prior agreement, theprofessional component shall be thirty-five percent of the scheduled fee.Vaccines, 07192072922301.11.34.72.5Special Otorhinolaryngologic 24932250.60.34.02.50.64.30.50.35.61.7CPT only copyright 2013 American Medical Association. CDT copyright 2013 American Dental Association. All Rights Reserved. ApplicableFARS/DFARS Restrictions Apply to Government Use.A-9
invasive Vascular Diagnostic .4Allergy and Clinical y and Neuromuscular 09591195912959136.48.510.211.913.8Central Nervous System Assessments/Tests(eg, Neuro-Cognitive, Mental Status, Speech Testing)961012.9Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, andChemotherapy and Other Highly Complex Drug orHighly Complex Biologic Agent odynamic Therapy965702.1965711.0CPT only copyright 2013 American Medical Association. CDT copyright 2013 American Dental Association. All Rights Reserved. ApplicableFARS/DFARS Restrictions Apply to Government Use.A-10
ysCodeUnitValueFollow-upDaysPhysical Medicine and ionValueWork hardening, per hour, maximum 4 hours . ollow-upDaysChiropractic Manipulative Treatment989400.9Special Services, Procedures and Reports99070HAR990802.6DENTAL 8D3353D3410D3421D34253.58.08.69.7CPT only copyright 2013 American Medical Association. CDT copyright 2013 American Dental Association. All Rights Reserved. ApplicableFARS/DFARS Restrictions Apply to Government Use.A-11
18.04.1Prosthodontics, thodontics, 75213.314.76.416.521.418.119.4Oral and Maxillofacial 7510D79606.38.13.55.7Adjunctive General ServicesD91102.2EVALUATION AND MANAGEMENTOffice or Other Outpatient 99212992138.10.81.82.799214992154.15.7Hospital Inpatient Services992322.4CPT only copyright 2013 American Medical Association. CDT copyright 2013 American Dental Association. All Rights Reserved. ApplicableFARS/DFARS Restrictions Apply to Government Use.A-12
ysCodeUnitValueFollow-upDaysEmergency Department ecial Evaluation and Management ServicesUnitCodeDescriptionValue99456A* Complex consultation pursuant to Section 386-79, HRS - work related or medical disabilityexamination by other than the treating physician that includes: completion of a medical history commensurate with the patient’s condition; performance of an examination commensurate with the patient’s condition; formulation of a diagnosis, assessment of capabilities and stability, and calculation ofimpairment; development of future medical treatment plan; completion of necessary documentation/certificates and report; and review of records relating to the patient’s condition.First hour. 6.099456B* Each additional 30 minute increment (an increment must be at least 30 minutes.) . 3.0*Department of Labor CodeBundled Services: Certain codes, such as telephone calls, are considered by the Health Care FinancingAdministration (HCFA) to be “bundled” services. Bundled services are not payable, norshould they be billed, when performed incident to or in conjunction with another service evenif the other service is performed on a different day. When services that are designated asbundled are denied, the physician may not collect from the patient.HAR:Use pertinent Hawaii Administrative Rule.CPT only copyright 2013 American Medical Association. CDT copyright 2013 American Dental Association. All Rights Reserved. ApplicableFARS/DFARS Restrictions Apply to Government Use.A-13
nonuse or interpretation of information contained in the Workers' Compensation Supplemental Medical Fee Schedule. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice .
