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§ 9789.13.3 Physician-Dispensed Drugs (Help with CPT Code 99070)

Summary

Section 9789.13.3 directs that the Pharmacy Fee Schedule determines reimbursement for physician-dispensed drugs.

The Physician Fee Schedule regulations should NOT be used to determine reimbursement for physician-dispensed drugs.

Do NOT use the Physician Fee Schedule for physician-dispensed drugs

Is CPT 99070 a valid code for billing physician-dispensed drugs?

Since the Pharmaceuticals part of the Official Medical Fee Schedule (OMFS) governs reimbursement for physician-dispensed drugs, CPT code 99070 remains the correct choice when billing for physician-dispensed drugs.

To determine reimbursement for services required to treat injured workers, the DWC maintains the OMFS which is made up of seven separate parts. Each part includes a fee schedule and associated billing regulations. One of these parts is designated as Pharmaceuticals and is used to determine reimbursement of pharmaceuticals, including physician-dispensed drugs.

As further clarification, the Physician Fee Schedule Regulations explicitly direct the use of the Pharmacy fee schedule when determining reimbursement for physician-dispensed drugs:

  • Section 9789.12.1(c): “Physicians and non-physician practitioners shall utilize other applicable parts of the OMFS to determine maximum fees for services or goods not covered by the Physician Fee Schedule, such as pharmaceuticals (section 9789.40)…”
  • Section 9789.13.3: “The maximum reimbursement for physician-dispensed drugs is determined pursuant to the Pharmaceutical Fee Section…”

Accordingly, for physician-dispensed drugs, denying 99070 CPT code by citing the Physician Fee Schedule Regulations as the reason for the denial is improper adjudication of CPT 99070 procedure code. Instead, any denial of physician-dispensed drugs must cite the fee schedule and regulations contained in the Pharmacy part of the OMFS.

California Code of Regulations (CCR)

§ 9789.13.3 Physician-Dispensed Drugs

Division of Workers’ Compensation Websites

Official Medical Fee Schedule

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