Calculating OMFS reimbursement is a complex process that involves multiple tables, formulas, and Billing Ground Rules. DaisyBill integrates all of these factors into OMFS calculations with the OMFS Calculator.
To calculate the Base Maximum Fee, the current RBRVS-based fee schedule (effective January 1, 2014 through December 31, 2018) requires the calculation of three separate components:
- Relative Value Units (RVUs)
- Average Statewide Geographic Adjustment Factors (GAFs)
- Conversion Factor (CF)
This article explains how to determine the Conversion Factor (CF).
Regulation 9789.19, which is the Update Table, provides the four new conversion factors effective as of April 1st, 2016. The four conversion factors are listed in the table below.
To calculate the base maximum fee, select the conversion factor that matches the type of HCPCS / Procedure Code.
- Anesthesia Conversion Factor: $28.8003
- Surgery Conversion Factor: $48.1743
- Radiology Conversion Factor: $47.4332
- Other Services Conversion Factor: $42.4361
Check the DWC website periodically, because conversion factors often change.
Section 9789.12.5 vs Section 9789.19
Labor Code section 5307.1 requires a four year transition period between the old fee schedule and the fully implemented new schedule based upon the RBRVS.
Section 9789.12.5(b)(2) sets forth the temporary conversion factors during the four-year transition period before adjustment for inflation and the Medicare relative value scale adjustment.
Regulation 9789.19 (the Update Table) sets forth the conversion factors after adjustment for inflation and Medicare relative value scale adjustment. The conversion factors set forth in the Update Table are the correct conversion factors to use in calculating maximum fees.
California Code of Regulations (CCR)
§ 9789.12.5 Conversion Factors
Division of Workers’ Compensation Websites
DaisyBill Solution
Thousands of workers’ comp professionals use DaisyBill’s Revenue Cycle Management software to compliantly process electronic bills. To learn more, schedule a no-pressure demo with one of our billing experts.