Updated Fee Schedule Effective January 1, 2021

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Effective January 1, 2021, WSI will implement the fee schedule changes described below.  WSI will publish a subsequent news article notification when the 2021 Fee Schedule files are available.

  1. Ambulance Fee Schedule
    • Update is based on the CPI-U
    • Reimbursement increased by 0.6%
  2. Ambulatory Surgical Center Fee Schedule
    • Update is based on the Market Basket for hospital services
    • WSI will reimburse for services in the Medicine Section of the AMA CPT® code set if listed on Medicare’s published list of covered ASC services
    • Conversion factor increased by 2.4% to $117.58
    • ASCs billing for device-intensive procedures must report a single line item charge, which includes the charges associated with both the service and device
  3. Anesthesia Fee Schedule
    • Update is based on the same percentage increase applied to the Medical Provider Fee Schedule
    • Conversion factor increased 3.0% to $66.87
  4. Clinic Laboratory Fee Schedule
    • Payment is set at 250% of North Dakota’s Medicare Laboratory fee schedule
    • Presumptive drug screening codes must be billed with CPT codes 80305, 80306, or 80307
    • Definitive drug testing must be billed with HCPC codes G0480-G0483
  5. Dental Fee Schedule
    • Payment is set using the Usual and Customary module of the Comprehensive Healthcare model database at the 70th percentile for the Fargo geographical area using the zip code 581xx
    • Reflects a consistent payment for providers in all locations
  6. Durable Medical Equipment Fee Schedule
    • Payment is set at 120% of North Dakota’s Medicare Fee Schedule
  7. Home Health Fee Schedule
    • Update is based on the Market Basket for Home Health services
    • Reimbursement increased by 2.3%
    • Increase is rounded to the nearest 50 cents
    • New Home Infusion Therapy (HIT) and existing HIT codes (HCPC “G” Codes) are under the DME fee schedule 
  8. Inpatient Hospital Fee Schedule
    • Update is a blended (operating and capital) Market Basket increase for hospital services, with adjustments made for anticipated DRG weight and coding changes 
    • Market Basket base rate increased by 2.3% to $10,160.00
    • The outlier threshold for 2021 is $66,500
  9. Long Term Care Hospital (LTCH) Fee Schedule
    • Fee Schedule is based on Diagnosis Related Groups (DRGs)
    • Market Basket base rate is $227,000.  With DRG weight changes, this will result in a 2.3% overall increase to payments
    • The outlier threshold for 2021 is $140,000
    • The LTCH fee schedule does not incorporate any new technology add-on payments
    • Providers must bill LTCH charges upon discharge only. WSI will not reimburse bills submitted as an interim stay
  10. Medical Provider Fee Schedule
    • Based on the Resource Based Relative Values System (RBRVS) Relative Value Unit (RVU) established by CMS
    • All services have a single conversion factor, including Chiropractic, E&M, Pathology, Medicine, PT and OT, Radiology and Surgery codes
    • CPT code changes from the American Medical Association (AMA) have been adopted
    • In following Medicare’s requirements, WSI will not recognize consult codes as valid codes
    • WSI has adopted Medicare’s new criteria for E&M codes 99202-99215
    • Conversion factor is $70.30.  With the RVU weight changes, this will result in a 3.0% overall increase in payments
  11. Outpatient Hospital Fee Schedule
    • Update is based on the Market Basket for hospital services
    • Conversion factor increased by 2.4% to $158.39

If you have questions about this article, please send an email to wsipr@nd.gov.  To receive provider news, subscribe to our Email Updates list. 

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