Medical Fee Services Newsletter Q3 2026

Regulatory Focus – 65.2-605.F

The Commission shall provide public access to information regarding the Virginia fee schedules for medical services, by categories of providers of fee scheduled medical services and for each medical community, through the Commission’s website.

2026 Schedule Updates

• Medical Inflation Adjustment: Maximum fees for codes carried over from the 2024 MFS to the 2026 MFS increased by 3.4% to reflect two years of medical inflation.

• Addition of New Codes: DRG, CPT, and HCPCS codes introduced in 2024 and 2025 were added to the 2026 MFS when they replaced terminated codes from the 2024 MFS, based on crosswalks provided by the American Medical Association.

• Removal of Retired Codes: Codes retired prior to January 1, 2025, were excluded from the 2026 MFS.

• Fee Adjustments for Revised Definitions: Codes with revised definitions in 2024 or 2025 had their maximum fees updated accordingly.

• The approved 2026 MFS and a detailed listing of all changes effective January 1, 2026, are available on the Commission’s website, accessed here.

MFS Administrative Determination Notice

Medical Fee Services announced an update to the Administrative Determination Notice in a redesigned format.

Key revisions include:

• Line‑Level Adjustment Details
• Each claim line now explicitly identifies the Ground Rule adjustment(s) applied.
• Fee Calculations
• Maximum fees are displayed as the calculated amount per code, ensuring transparency in fee determination.

MFS Administrative Determination Notice Tutorial

Training on the use and interpretation of the new Administrative Determination Notice and is available below, or on VWC’s YouTube channel.

Frequently Asked Questions

Q: I am a tertiary hospital located outside of the state. Is it possible to use the calculator to determine Type One Teaching Hospital fees for my facility? If yes, where is that information entered?

A: Type One Teaching Hospitals are state of Virginia‑owned teaching hospitals that have been designated as such since January 1, 1996. These facilities exist only in Regions 2 and 3 and have maximum fee values assigned to all applicable billing codes. As a result, if your service region is outside Regions 2 or 3, or if the billing code does not qualify, selecting a Type One Teaching Hospital will return a result of Not Applicable (N/A).

Q: The payment received is not what is listed in the VA Medical Fee Schedule. What falls under the jurisdiction of the VA Medical Fee Schedule?

A: Payments from payers may be lower or higher than the medical fee schedules. In the absence of a contract, the Virginia Medical Fee Schedule is a tool that the Commission uses to determine the fee schedule maximum assigned amount for medical claims that have an award on file and a dispute has been submitted to the Commission to determine reimbursement for medical treatment provided to an injured worker.

Q. There is an award for medical benefits; however, the payer denied payment for medical services rendered to the injured worker and I do not think this is correct. Is there anything the Virginia Workers Compensation Commission can do?

A: In the event the medical provider and payer cannot agree on proper reimbursement for medical services rendered under the Virginia Workers Compensation Act, a request may be submitted to have the dispute reviewed administratively. An MFS Dispute Request form can be filed directly with the Commission. More information on the MFS dispute Resolution process can be located here.

Q: I’ve submitted my bill to the payer for reimbursement, I don’t agree with what they are recommending for payment, the explanation of review indicates I should forward a request for reconsideration to the Commission.

A: The Commission determines the award status for medical benefits, establishes medical fee schedule reimbursement rates for medical treatment provided, and issues determinations for disputes that are submitted to the Commission for reimbursement disagreements. The Commission does not review reconsideration requests or issue payments for medical treatment provided to injured workers. Requests for reconsideration must be filed directly with the payer.

Q: A code was denied as not being listed in the fee schedule, does this mean that payers do not have to pay for these medical services?

A: No, this does not mean that payers do not have to issue a payment. The Ground Rules document identifies that the absence of any code from the medical fee schedule does not mean that the medical services corresponding to that code are services outside of the scope of the coverage provided by the Virginia Workers’ Compensation Act. If the parties cannot reach an amicable agreement for the reimbursement amount for the code. Either party may submit a dispute request to the Commission to have the fee schedule maximum assigned amount determined.

Q. We are establishing our business rules for reimbursement using the medical fee schedule maximum assigned amounts. If there is not a maximum amount listed in the schedule we cannot come to an agreement with the medical provider for reimbursement, can we just pay 80% if billed charges?

A. The Medical Fee Services Department cannot provide directions on any stakeholder’s internal business processes. The Medical Fee Services Department can review the issues identified in a dispute submitted to the Commission and will issue a formal determination that defines the fee scheduled maximum assigned amount.

Q. The medical bill includes implant charges that are excessive, why does the Medical Fee Services Department not review the charges to determine the usual and customary amounts?

A. The implementation of the Virginia Medical Fee Schedules effective on 01/01/2018, replaced the usual and customary standard for implant charges for all dates of service on or after the effective date. Under the Virginia Workers’ Compensation Medical Fee Schedules, reimbursement rules for implantable medical devices depend entirely on how the device is coded and how the maximum fee is calculated.

Q. Medicare National Correct Coding Initiative (NCCI) edits include specific code combination edits that limit incorrect code combinations. Why was a code I denied allowed in the Medical Fee Service’s administrative determination?

A. There are often ambiguous details within complex medical procedures that are often not captured in simply reviewing the numerical code. The Medical Fee Services Department reviews the medical services first and then determines if the code used to describe the services meets applicable coding conventions.

Q. We are in another state; however, our facility has a Level I trauma center designation, are we eligible for the traumatic injury exclusion?

A. No, The Ground Rules document definition for Level I or Level II Trauma Center ” means a hospital in the Commonwealth designated by the Board of Health as a Level I or Level II trauma center pursuant to the Statewide Emergency Medical Services Plan developed in accordance with § 32.1-111.3

2026 MFS Symposium

October 20, 2026

Save the date for the 2026 MFS Symposium, again held during the first day of the Virginia Workers’ Compensation ​Commission’s Educational Conference on October 20, 2026. Join the MFS Department to gain additional insights into the following topics:

Navigating the MFS Dispute Resolution Process

• Navigate the dispute submission process.
• Review documentation requirements including required billing forms and supporting information.
• Gain understanding of impact of extension requests and how they affect timelines.

Understanding the MFS Administrative Determination

• How determinations are generated and how to interpret payment adjustments or denials.
• Brief overview of the MFS Calculator, required inputs, and alignment with current ground rules.
• What to know about calculator limitations and when manual review applies.

Post‑MFS 2026 Issue Submission

• Snapshot of the biennial revision submission process and stakeholder roles.
• Common stakeholder questions identifying specific unlisted codes
• How missing codes are identified, validated, and incorporated.
• Overview of DRG versioning for the 2026 release and its impact.

What’s Next for MFS

• Preview of upcoming enhancements, including updated forms and expanded MFS WebFile functionality.
• Planned improvements to the calculator interface and logic transparency.

Please complete our feedback survey concerning the MFS Symposium here by August 17, 2026.

Helpful Links

Medical Fee Services Website

2026 Medical Fee Schedules

MFS Training Opportunities

Topics below are available in-person or virtually.

Understanding the Nuts and Bolts of the Medical Fee Schedules

• Provides a comprehensive review of the MFS Regulations
• Introduces the roles and responsibilities of the Commission and Regulatory Advisory Panel
• Explores key MFS schedule data elements
• Explains the role of the Ground Rules

Impacts and Influences of the Medical Fee Schedules

• Clarifies implications for Providers and Payers
• Illustrates the MFS review and maintenance of schedules

Medical Fee Schedule Dispute Resolution

• Reviews forms and notices
• Gives examples of required documentation
• Provides examples of key applicable coding conventions
• Discusses MFS exclusions and dispute resolution

Breaking down the Administrative Determination

• Reviews the importance of supporting medical records
• Explores the administrative decision components
• Discusses the process to appeal the decision

Medical Provider Inquiry Forms

• What are Medical Provider Inquiry (MPI) Forms?
• How to properly fill out an MPI form
• Submitting an MPI form to the Commission

MFS Calculator Training

• Review the statutory governance and how it influences Commission Medical Fee Services
  activities such as the development of the calculator.
• Identify key workers’ compensation system experiences and how they intersect with the
  Commission’s Medical Fee Services goals.
• Review key considerations in navigating the calculator in order to utilize the tool effectively.
• Review the outcomes for medical service codes and applicable Ground Rule adjustments for
  maximum fee values.

2026 Schedule Updates

• The 2026 MFS and a detailed listing of all changes effective January 1, 2026, are available on
  the Commission’s website.

Tutorial Availability:

• Training on the use and interpretation of the new Administrative Determination Notice and is
  available here.

Do you have new staff?

Would you like an overview of the medical fee schedules or to be
included in the virtual quarterly training sessions planned for 2026?

Email us here.

Ways to Contact MFS

Contact the Medical Fee Services Department toll-free at 877-664-2566.

Below are recommendations for the best ways to contact MFS depending on your need.

Fax

804-823-6932

• Medical Provider Inquiries (MPI)
• Dispute request forms
• Dispute withdrawal
• Supporting documentation

Email

[email protected]

• Administration of the Medical Fee Schedule
• Medical Fee Dispute Resolution process
• Education and training for the public
• General inquiries

Responses will be provided within 48-72 hours.