The material below is provided for information purposes only and is not intended as a primary source for repricing of Pennsylvania Workers’ Compensation services. Updates are made periodically by the Bureau when HCPCS or fee schedule changes are indicated. The Part B Fee Schedule web pages were last updated: August 2024. If desired, it is the user’s responsibility to retain historic records of previous fee schedules.
Generally, since January 1, 1995, medical fees for outpatient services rendered under the Act are capped at 113% of the Medicare reimbursement rate. Payment rates are then frozen and thereafter updated annually by the percentage change in the Statewide average weekly wage. 34 Pa. Code §§ 127.101(a) and 127.153.
With respect to outpatient care, the regulations provide: "If a Medicare allowance does not exist for a reported HCPCS code, or successor codes, the provider shall be paid either 80 percent of the usual and customary charge, or the actual charge, whichever is lower." 34 Pa. Code § 127.103(c).
Since November 1, 2010, when resolving applications for fee review under 34 Pa. Code § 127.256, the Department utilizes the 85th percentile of the relative value benchmark database published by FAIR Health to determine the usual and customary charge (U&C) as defined in 34 Pa. Code § 127.3.
Of note, J codes are not included on this Part B fee schedule; in accordance with 34 Pa. Code § 127.131(a), “Payments for prescription drugs and professional pharmaceutical services shall be limited to 110% of the average wholesale price (AWP) of the product.” The Bureau currently utilizes Red Book, published by Truven Health Analytics (IBM), to determine the AWP.
Part B Fee Schedules
Please click on the CPT/HCPCS applicable code range to look up specific codes.
User Keys:
X = Not Applicable
# = No FAIR Health U&C or Medicare allowance available
* = FAIR Health U&C data may be available depending on the zip code where the service was rendered