Summary

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, 2019) requires the calculation of three separate components:

1. Relative Value Units (RVUs)
2. Geographic Practice Cost Indices (GPCIs)
3. Conversion Factor (CF)

This article explains how to determine the correct Conversion Factor (CF) for 2021.

Regulation 9789.19, which is the Physician Services Fee Schedule Update Table, provides the Conversion Factors for Anesthesia and Other Services effective March 1st, 2021 and are listed in the table below. These are, as of 2018, the only two CFs; Radiology and Surgery are now included in Other Services.

CMS’ Medicare National Physician Fee Schedule Conversion Factors adjusted for MEI and Relative Value Scale adjustment factor

For services rendered on or after March 1, 2021: Anesthesia Conversion Factor: $27.6911 Other Services Conversion Factor: $45.87

To calculate the base maximum fee, select the Conversion Factor that matches the type of HCPCS / Procedure Code.

• Anesthesia Conversion Factor: $27.6911
• Other Services Conversion Factor: $45.87

Check the DWC website periodically, because conversion factors change annually.

For a complete outline of how to apply the Base Maximum Fee Formula, read our article Reimbursement for Physician Services Rendered on or After January 1, 2019.

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

Official Medical Fee Schedule

DaisyBill Solution

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