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§ 9789.12.14 California Specific Codes

A full list of California-specific codes with reimbursement information effective March 1, 2017. The list includes the previous reimbursements, as well as the difference between the previous payments and the new payments by percentage.

§ 9789.12.7 CMS National Physician Fee Schedule Relative Value File / Relative Value Units (RVUs)

This article explains how to access the Relative Value Units (RVUs) used in the Base Maximum Fee calculation. We explain the method for calculating reimbursement, and offer instructions for accessing the necessary resources.

§ 9789.12.2 Calculation of the Maximum Reasonable Fee - Services Other than Anesthesia

This article breaks down the process for calculating the Maximum Reasonable Fee for services excluding anesthesia. From determining place of service to applying the necessary values and ground rules, we explain how it’s done.

§ 9789.12.13 Correct Coding Initiative

Effective January 1st, 2014, the California Division of Workers’ Compensation (DWC) adapted The National Correct Coding Initiative Edits, including Medically Unlikely Edits.

§ 9789.12.12 Consultation Services Coding - Use of Visit Codes

This article explains the circumstances under which a consultation report is reimbursable. We also include links to the relevant regulatory codes for reference.

§ 9789.12.11 Evaluation and Management: Coding - New Patient; Documentation

A guide to billing for evaluation and management (E/M) services for new patients, complete with links to the necessary regulatory information and detailed instructions

§ 9789.11 Physician Services Rendered on or After July 1, 2004, but Before January 1, 2014

For physician services rendered from July 2004 through December 31st, 2013, regulations § 9789.10 and § 9789.11 affected reimbursements. After January 1st, 2014, the physician fee schedule changed to the RBRVS system. Here’s how to calculate reimbursements for the affected dates of service.

§ 9789.12.8 Status Codes

Effective January 1st, 2014, the California Division of Workers’ Compensation (DWC) adapted Medicare CPT/HCPCS Status Codes to further provide reimbursement information for various Procedure Codes.  

§ 9789.12.1 Physician Fee Schedule: Official Medical Fee Schedule for Physician and Non-Physician Practitioner Services – For Services Rendered On or After January 1, 2014

For medical services rendered on and after January 1st, 2014, the RBRVU Physician Fee schedule consists of 48 Regulations, including 40 fee-affecting regulations. Knowing and understanding these additional fee-affecting regulations is critical to determining the correct reimbursement for services.

§ 9789.18.7 Anesthesia - Medical and Surgical Services Furnished in Addition to Anesthesia Procedure

For medical services rendered on and after January 1st, 2014, the RBRVU Physician Fee schedule consists of 48 Regulations, including 40 fee-affecting regulations. Knowing and understanding these additional fee-affecting regulations is critical to determining the correct reimbursement for services.

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

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

§ 9789.13.1 Supplies

For medical services rendered on and after January 1st, 2014, the RBRVU Physician Services Fee Schedule consists of 48 Regulations, including 40 fee-affecting regulations. Knowing and understanding these additional fee-affecting regulations is critical to determining the correct reimbursement for services.

§ 9789.13.2 Physician-Administered Drugs, Biologicals, Vaccines, Blood Products

For medical services rendered on and after January 1st, 2014, the RBRVU Physician Services Fee Schedule consists of 48 Regulations, including 40 fee-affecting regulations. Knowing and understanding these additional fee-affecting regulations is critical to determining the correct reimbursement for services.

§ 9789.19 Update Table

The Update Table maintains all of the reference materials used by the fee schedule regulations, including calculation values used to determine the base maximum fees.

§ 9789.12.6 Health Professional Shortage Area Bonus Payment: Primary Care; Mental Health

For medical services rendered on and after January 1st, 2014, the RBRVU Physician Fee schedule consists of 48 Regulations. Knowing and understanding these additional fee-affecting regulations is critical to determining the correct reimbursement for services.

§ 9789.12.5 Conversion Factors

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.

§ 9789.12.15 California Specific Modifiers

A modifier -30 is a situational billing element which alerts when a consultation is required for a Medical-Legal Evaluation.

§ 9789.12.10 Coding; Current Procedural Terminology©, Fourth Edition

For medical services rendered on and after January 1st, 2014, the RBRVU Physician Fee schedule consists of 48 Regulations. Knowing and understanding these additional fee-affecting regulations is critical to determining the correct reimbursement for services.

§ 9789.10 Physician Services Rendered on or After July 1, 2004, but Before January 1, 2014 - Definitions

For physician services rendered from July 2004 through December 31st, 2013, regulations § 9789.10 and § 9789.11 determined reimbursements. After January 1st, 2014, the physician fee schedule changed to RBRVU-based reimbursements.

§ 9789.12.4 “By Report” - Reimbursement for Unlisted Procedures / Procedures Lacking RBRVUs

Calculating OMFS reimbursement is a complex process that involves multiple tables, formulas and Billing Ground Rules. The OMFS Calculator takes into consideration all of these factors when providing OMFS reimbursement.

§ 9789.15.6 Diagnostic Cardiovascular Procedures - Multiple Procedure Reduction

Under certain circumstances, the Physician Fee Schedule reduces some reimbursements when Multiple Procedures are provided on the same day. These reductions are known as MPPRs.

§ 9789.15.5 Ophthalmology Multiple Procedure Reduction

Under certain circumstances, the Physician Fee Schedule reduces reimbursement when Multiple Procedures are provided on the same day. These reductions are known as MPPRs.

§ 9789.12.3 Status Codes C, I, N and R

Effective January 1st, 2014, the California Division of Workers’ Compensation (DWC) adapted Medicare CPT/HCPCS Status Codes to further provide reimbursement information for various Procedure Codes.

§ 9789.16.5(c) Determining Maximum Payment for Multiple Surgeries

The Physician Fee Schedule reduces some surgical reimbursements when multiple surgical procedures are provided during the same surgery.

§ 9789.18.1 Payment for Anesthesia Services - General Payment Rule

Calculating OMFS reimbursement for Anesthesia Services is a complex process that involves multiple tables and formulas.

§ 9789.12.9 Professional Component (PC)/Technical Component (TC) Indicator

Effective January 1st, 2014, the California Division of Workers’ Compensation (DWC) adapted Medicare PC/TC Indicators for workers’ compensation.

§ 9789.15.1 Non-Physician Practitioner (NPP) - Payment Methodology

Per section 9789.15.1, for services provided by Physician Assistants, Nurse Practitioners, and Clinical Nurse Specialists, the Physician Fee Schedule regulations reduce payment to 85% of the calculated reimbursement.

§ 9789.14 Reimbursement for Reports, Duplicate Reports, Chart Notes

For medical services rendered on and after January 1st, 2014, the RBRVU Physician Fee schedule consists of 48 Regulations, including 40 fee-affecting regulations. Knowing and understanding these additional fee-affecting regulations is critical to determining the correct reimbursement for services.

§ 9789.17.1 Radiology Diagnostic Imaging Multiple Procedures

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.

§ 9789.16.4 Surgery - Global Fee; Exception: Circumstances Allowing E&M Code During the Global Period; Primary Treating Physician's Progress Report (PR-2)

For surgical codes subject to the workers' comp global period, the physician may be reimbursed for providing E&M (Evaluation and Management) services in certain circumstances. Those E&M services must be in excess of the total number of E&M visits listed for the surgical code in Section 9789.16.4, and only medically necessary E&M services in excess of that number may be separately billed.

§ 9789.16.1 Surgery - Global Fee

Surgical procedures are assigned a global period of zero, 10, or 90 days. The global period for each procedure is specified in the 2014 Medicare National Physician Fee Schedule Relative Value File, column O entitled "Glob Days".

§ 9789.15.4 Physical Medicine / Chiropractic / Acupuncture Multiple Procedure Payment Reduction; Pre-Authorization for Specified Procedure / Modality Services

There are four types of reductions for physical medicine:

Finding the Medi-Cal Rates File

The Medi-Cal Rates are updated monthly and published on the Medi-Cal website on the 16th of the month. To download the Medi-Cal Rates file, go directly to the Medi-Cal page. Or follow the instructions below to download the Medi-Cal Rates file from the DWC website.

How do I bill for physician-administered pharmaceuticals?

ANSWER: The regulation determining reimbursements for physician-administered drugs, biologicals and blood products is extremely complex and difficult to follow.

How to Determine the Correct E/M Code

To determine appropriate coding for Evaluation and Management (E&M) services, use either the 1995 or 1997 edition of CMS’ Documentation Guidelines for Evaluation and Management Services.  The following outlines the overlap of both of these documents.

Administered vs Dispensed Pharmaceuticals

For California workers' compensation purposes, the definition of "administer" is "the direct application of a drug or device to the body of a patient by injection, inhalation, ingestion, or other means." The Physician fee schedule allows physicians to both administer and dispense pharmaceuticals to patients.

2017 Physician and Non-Physician Fee Schedule

The California Division of Workers’ Compensation (DWC) posted an order announcing their upcoming adjustment to the Physician and Non-Physician section of the Official Medical Fee Schedule (OMFS). The move was widely expected, as it allows the DWC to conform to the Medicare payment system, as required by Section 5307.1 of the California Labor Code.

CPT Codes 99358 & 99359: Non-Face-To-Face Services

The new Physician and Non-Physician Fee Schedule goes into effect on March 1, 2017. With it come a variety of new CPT codes, including 99358 and 99359. Both allow physicians or nonphysician practitioners to bill for prolonged services that are not face-to-face.

New Telehealth Place of Service Code

The new Physician and Non-Physician Fee Schedule, effective March 1, 2017, adds many reimbursable telemedicine codes. It also adds a new Place of Service Code – 02. Remember, all treatment, including telemedicine, requires prior authorization from the claims administrator.

Incident To Billing Provision for California Workers' Comp

Contrary to popular belief, bills for services rendered by Physician Assistants or other NPPs may be reimbursed at 100% of the Official Medical Fee Schedule (OMFS). “Incident to” billing allows NPPs to bill with a physician’s National Provider Identifier (NPI) number – provided strict criteria concerning that physician’s supervision and availability are met.

Understanding CA-Specific Code WC007

Everything changed when the Division of Workers’ Compensation adopted the RBRVS-based Physician Fee schedule on January 1, 2014. One specific consequence of the shift to RBRVS: The elimination of CPT 99080 as a reimbursable code for consultation reports, and the erroneous use of California-specific code WC007 in its place.

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