The California workers’ comp regulations validating CPT Code 99070 for billing physician-dispensed drugs are difficult to find and difficult to understand. We created a breakdown of these regulations, including where to find the regulations and how to correctly interpret them.
Frequently Asked Question
Q: Where can I find the regulations for CPT Code 99070 for physician-dispensed drugs?
A: The new Physician Fee Schedule Regulations are in Title 8 of the California Code of Regulations, § 9789.12.1.
Explanation
The Department of Workers’ Compensation maintains the Official Medical Fee Schedule (OMFS), which consists of seven separate parts. Each of the seven parts of the OMFS have a fee schedule and associated billing requirements. For the Physician services part of the OMFS, the new Physician Fee Schedule Regulations became effective for all dates of service on or after January 1, 2014.
Per Section 9789.12.1 of the new Physician Fee Schedule Regulations, the Pharmaceutical Fee Schedule governs reimbursements for physician-dispensed drugs. For physician-dispensed drugs, denying CPT code 99070 by citing the Physician Fee Schedule Regulations as the reason for the denial is improper adjudication of CPT 99070. Instead, any denial of physician-dispensed drugs must cite the fee schedule and regulations contained in the Pharmaceuticals part of the OMFS.
Section 9789.40 of the Pharmacy Regulation provides explicit instructions for calculating reimbursements: “The maximum reasonable fee for pharmaceuticals and pharmacy services rendered after January 1, 2004 is 100 percent of the fee reimbursement prescribed in the relevant Medi-Cal payment system, including the Medi-Cal professional fee for dispensing.”
To determine the correct reimbursement for physician-dispensed pharmaceuticals for dates of service as of the most recent Wednesday, use the DWC calculator: Workers’ Compensation pharmacy fee schedule - Simple prescription. Every Wednesday afternoon, the DWC updates and replaces the reimbursements listed in the pharmacy fee schedule.
Additional Information
California DIR Official Medical Fee Schedule
California Code of Regulations §9789.13.3 (Physician Fee Schedule Regulations)
California Code of Regulations §9789.40 (Pharmaceutical Fee Schedule Regulations)
DaisyBill Resources
Blog Post: Warning: The DWC's Pharmacy Fee Schedule Is Not Always Accurate
Blog Post: Maximus Independent Bill Review: Incorrectly Denied IBRs
Webinar: Workers’ Compensation Fee Schedules
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