A Detailed Explanation is provided for each Procedure Code entered. The Detailed Explanation provides information about the calculation factors DaisyBill uses to determine OMFS reimbursement.
Let’s break down a Detailed Explanation.
A. Fee Schedule
The Procedure Code falls under this Fee Schedule.
A short Description of the Procedure Code.
C. Status Code Explanation
The Status Code Explanation provides the DWC description of the Medicare Status Code assigned to the Procedure Code per § 9789.12.8. Status Codes. Effective 1/1/14, the California Division of Workers’ Compensation (DWC) adapted Medicare Status Codes (but not definitions) to further provide reimbursement information for various Procedure Codes.
D. Effective Dates of Service
The Effective Dates of Service provides the Dates of Service the calculated OMFS reimbursement amount is effective.
E. RVUs, GAFs/GPCIs, Conversion Factor
The current RBRVS-based fee schedule (effective January 1, 2019) has three separate components (RVUs, GPCIs, Conversion Factor) that must be calculated together to obtain a code’s Base Maximum Fee. The OMFS Calculator displays the effective components and calculations for the given Date of Service.
For dates of service after January 1, 2014 but before January 1, 2019, the three components of the fee schedule were RVUs, GAFs, Conversion Factor which had to be calculated together to obtain a code’s Base Maximum Fee.
For more information, see Calculator Results Explained.
F. Base Maximum Fee
The Base Maximum Fee is the maximum reimbursement per the OMFS for the Procedure Code on the given Date of Service. The Base Maximum Fee does not include calculations for Billing Ground Rules (eg., surgical cascading, MPPR, NCCI, MUE). The Base Maximum Fee may differ from the OMFS reimbursement calculated which does account for Billing Ground Rules.
G. Billing Ground Rules
Billing Ground Rules are fee affecting regulations that determine the calculated OMFS reimbursement. Billing Ground Rules are applied to the Base Maximum Fee calculation to produce the OMFS reimbursement.
H. NCCI Edits
Per the Official Medical Fee Schedule § 9789.12.1 for Physician and Non-Physician Practitioner Services, the OMFS Calculator incorporates the following fee-affecting reimbursement rules:
- Physician National Correct Coding Initiative Edits (NCCI) Edits: adopted by the CMS for payments for medical services under the Physician Fee Schedule
- Practitioner Services Medically Unlikely Edit (MUE) Table: Medically Unlikely Edits are published by CMS
For more information see Physician Services NCCI Edits.
I. HCPCS Information
HCPCS Information displays additional HCPCS information provided in Medicare’s RVU Table for the Procedure Code.
Now back to beautiful billing!