reglab/statecodes huggingface dataset:
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.17.2 - Radiology Consultations

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
(1)
					 Only one interpretation of an x-ray procedure shall be reimbursed. This
					 interpretation of an x-ray procedure must directly contribute to the diagnosis
					 and treatment of the patient. The physician must prepare a signed written
					 report of his or her interpretation of the results of the x-ray. The
					 professional component of the x-ray procedure shall be paid using modifier -26.
					 A professional component billing based on a
review
of the
					 findings of these x-ray procedures, without a complete written report similar
					 to that which would be prepared by a specialist in the field, does not meet the
					 conditions for separate payment of the service.
(2) Reimbursement for a second interpretation
					 shall only be allowed under unusual circumstances (for which documentation is
					 provided), such as a questionable finding for which the physician performing
					 the initial interpretation believes another physician's expertise is needed or
					 a changed diagnosis resulting from a second interpretation of the results of
					 the procedure. This second interpretation shall be identified through the use
					 of modifier "-77".
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.17.3 - Additional Payment Reductions for Certain Diagnostic Imaging Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) For services
					 rendered on or after March 1, 2017, payment of X-ray imaging services that are
					 taken using film is made at:
(1) 80 percent of
					 a technical component-only service;
(2) 80 percent of the technical component of
					 a global service.
Services for X-rays using film must be identified through
						the use of modifier "FX." For services subject to both the multiple procedure
						payment reduction (MPPR) set forth in section
						9789.17.1, and the "FX" modifier
						reduction on imaging, the "FX" modifier reduction should be applied before the
						MPPR for radiology diagnostic imaging procedures.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.18.1 - Payment for Anesthesia Services - General Payment Rule

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) For dates of service on or after January
					 1, 2014, but before January 1, 2019:
The fee schedule amount for physician anesthesia services
						is, with the exceptions noted, based on allowable base and time units
						multiplied by an anesthesia conversion factor and statewide anesthesia
						GAF.
The maximum reasonable fee for physician and
						non-physician practitioner anesthesia services shall be calculated as
						follows:
[Base Unit + Time Unit] * CF * Statewide Anesthesia GAF =
						Base Maximum Fee
The base maximum fee for the procedure code is the
						maximum reasonable fee, except as otherwise provided by applicable provisions
						of this fee schedule, including but not limited to the application of ground
						rules and modifiers that affect reimbursement.
(1) Base Unit: The base unit for each
					 anesthesia procedure is listed in a file entitled "Anesthesia Base Units by CPT
					 Code," which is adopted and incorporated by reference. See Section
					 9789.19 for reference to the
					 "Anesthesia Base Units by CPT Code" file, by date of service.
(2) Time Units: The way in which time units
					 are to be calculated is set forth in Section
					 9789.18.8.
(3) Anesthesia Conversion Factor and
					 Statewide Anesthesia GAF: See Section
					 9789.19 for the anesthesia
					 conversion factor and statewide anesthesia GAF, by date of
					 service.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.18.3 - Anesthesia - Medically Directed Rate

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Payment for the physician's medical
					 direction service is determined on the basis of 50 percent of the allowance for
					 the service performed by the physician alone. Medical direction occurs if the
					 physician medically directs qualified individuals (all of whom could be CRNAs,
					 AAs, interns, residents, or combinations of these individuals) in two, three,
					 or four concurrent cases and the physician performs all the following
					 activities:
(1) Performs a pre-anesthetic
					 examination and evaluation;
(2)
					 Prescribes the anesthesia plan;
(3)
					 Personally participates in the most demanding procedures in the anesthesia
					 plan, including, if applicable, induction and emergence;
(4) Ensures that any procedures in the
					 anesthesia plan that he or she does not perform are performed by a qualified
					 anesthetist;
(5) Monitors the
					 course of anesthesia administration at frequent intervals;
(6) Remains physically present and available
					 for immediate diagnosis and treatment of emergencies; and
(7) Provides indicated-post-anesthesia
					 care.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.18.4 - Anesthesia - Definition of Concurrent Medically Directed Anesthesia Procedures

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Concurrency is defined with regard to the maximum number
						of procedures that the physician is medically directing within the context of a
						single procedure and whether these other procedures overlap each
						other.
1. New
						section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and
						print only pursuant to Government Code section
						11340.9(g)
						(Register 2013, No. 39).
Note: Authority: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  5307.1 and
						  5307.11, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.18.5 - Anesthesia - Medically Supervised Rate

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Only three base units per procedure is allowed when the
						anesthesiologist is involved in furnishing more than four procedures
						concurrently or is performing other services while directing the concurrent
						procedures. An additional time unit may be recognized if the physician can
						document he or she was present at induction.
1. New
						section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and
						print only pursuant to Government Code section
						11340.9(g)
						(Register 2013, No. 39).
Note: Authority: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  5307.1 and
						  5307.11, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.18.6 - Anesthesia - Multiple Anesthesia Procedures

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Physicians and non-physician
					 practitioners shall bill for the anesthesia services associated with multiple
					 bilateral surgeries by reporting the anesthesia procedure with the highest base
					 unit value with the multiple procedure modifier "-51." The total time for all
					 procedures shall be reported in the line item with the highest base unit
					 value.
(b) If the same anesthesia
					 CPT code applies to two or more of the surgical procedures, billers enter the
					 anesthesia code with the "-51" modifier and the number of surgeries to which
					 the modified CPT code applies.
(c)
					 Payment can be made under the fee schedule for anesthesia services associated
					 with multiple surgical procedures or multiple bilateral procedures. The maximum
					 fee is determined based on the base unit of the anesthesia procedure with the
					 highest base unit value and time units based on the actual anesthesia time of
					 the multiple procedures.
1. New
						section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and
						print only pursuant to Government Code section
						11340.9(g)
						(Register 2013, No. 39).
Note: Authority: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  5307.1 and
						  5307.11, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.18.7 - Anesthesia - Medical and Surgical Services Furnished in Addition to Anesthesia Procedure

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Payment may be made under the fee schedule for specific
						medical and surgical services furnished by the anesthesiologist as long as
						these services are reasonable and medically necessary and provided that other
						rebundling and ground rule provisions do not preclude separate payment. These
						services may be furnished in conjunction with the anesthesia procedure to the
						patient or may be furnished as single services, e.g., during the day of or the
						day before the anesthesia service. These services include the insertion of a
						Swan Ganz catheter, the insertion of central venous pressure lines, emergency
						intubation, and critical care visits.
1. New
						section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and
						print only pursuant to Government Code section
						11340.9(g)
						(Register 2013, No. 39).
Note: Authority: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  5307.1 and
						  5307.11, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.18.8 - Anesthesia - Time and Calculation of Anesthesia Time Units

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Anesthesia time is defined as the period
					 during which an anesthesia practitioner is present with the patient. It starts
					 when the anesthesia practitioner begins to prepare the patient for anesthesia
					 services in the operating room or an equivalent area and ends when the
					 anesthesia practitioner is no longer furnishing anesthesia services to the
					 patient, that is, when the patient may be placed safely under postoperative
					 care. Anesthesia time is a continuous time period from the start of anesthesia
					 to the end of an anesthesia service. In counting anesthesia time, the
					 anesthesia practitioner can add blocks of time around an interruption in
					 anesthesia time as long as the anesthesia practitioner is furnishing continuous
					 anesthesia care within the time periods around the interruption.
(b) Time units are computed by dividing the
					 actual reported anesthesia time by 15 minutes. Round the time unit to one
					 decimal place.
(c) Time units are
					 not allowed for CPT code 01996.
For purposes of this section, "anesthesia practitioner"
						means a physician who performs the anesthesia service alone, a CRNA who is not
						medically directed, or a CRNA or AA, who is medically directed. The physician
						who medically directs the CRNA or AA would ordinarily report the same time as
						the CRNA or AA reports for the CRNA service.
1. New
						section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and
						print only pursuant to Government Code section
						11340.9(g)
						(Register 2013, No. 39).
Note: Authority: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  5307.1 and
						  5307.11, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.18.9 - Anesthesia - Base Unit Reduction for Concurrent Medically Directed Procedures

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
If the physician medically directs concurrent medically
						directed procedures, reduce the number of base units for each concurrent
						procedure as follows.
(a) For two
					 concurrent procedures, the base unit on each procedure is reduced 10
					 percent.
(b) For three concurrent
					 procedures, the base unit on each procedure is reduced 25 percent.
(c) For four concurrent procedures, the base
					 on each concurrent procedure is reduced 40 percent.
(d) If the physician medically directs
					 concurrent procedures and any of the concurrent procedures are cataract or
					 iridectomy anesthesia, reduce the base units for each cataract or iridectomy
					 procedure by 10 percent.
1. New
						section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and
						print only pursuant to Government Code section
						11340.9(g)
						(Register 2013, No. 39).
Note: Authority: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  5307.1 and
						  5307.11, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.18.10 - Anesthesia - Monitored Anesthesia Care

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The physician or non-physician practitioner shall be
						reimbursed for reasonable and medically necessary monitored anesthesia care
						services on the same basis as other anesthesia services. Anesthesiologists use
						modifier QS to report monitored anesthesia care cases. Monitored anesthesia
						care involves the intra-operative monitoring by a physician or qualified
						individual under the medical direction of a physician or of the patient's vital
						physiological signs in anticipation of the need for administration of general
						anesthesia or of the development of adverse physiological patient reaction to
						the surgical procedure. It also includes the performance of a pre-anesthetic
						examination and evaluation, prescription of the anesthesia care required,
						administration of any necessary oral or parenteral medications (e.g., atropine,
						demerol, valium) and provision of indicated postoperative anesthesia care.
						Payment is made under the fee schedule using the payment rules in section
						9789.18.2 if the physician
						personally performs the monitored anesthesia care case or under the rules in
						section 9789.18.3 if the physician
						medically directs four or fewer concurrent cases and monitored anesthesia care
						represents one or more of these concurrent cases.
1. New
						section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and
						print only pursuant to Government Code section
						11340.9(g)
						(Register 2013, No. 39).
Note: Authority: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  5307.1 and
						  5307.11, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.18.11 - Anesthesia Claims Modifiers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Physicians shall report the appropriate anesthesia
						modifier to denote whether the service was personally performed, medically
						directed, or medically supervised in addition to any applicable CPT
						modifier.
Specific anesthesia modifiers include:
AA -- Anesthesia Services performed personally by the
						anesthesiologist;
AD -- Medical Supervision by a physician; more than 4
						concurrent anesthesia procedures;
G8 -- Monitored anesthesia care (MAC) for deep complex
						complicated, or markedly invasive surgical procedures;
G9 -- Monitored anesthesia care for patient who has a
						history of severe cardio- pulmonary condition;
QK -- Medical direction of two, three or four concurrent
						anesthesia procedures involving qualified individuals;
QS -- Monitored anesthesia care service -- The QS
						modifier is for informational purposes. Providers must report actual anesthesia
						time and payment modifier on the claim;
QX -- CRNA service; with medical direction by a
						physician;
QY -- Medical direction of one qualified non-physician
						anesthetist by an anesthesiologist;
QZ -- CRNA service: without medical direction by a
						physician; and
GC -- these services have been performed by a resident
						under the direction of a teaching physician. The GC modifier is reported by the
						teaching physician to indicate he/she rendered the service in compliance with
						the teaching physician requirements in section
						9789.18.2. One of the payment
						modifiers must be used in conjunction with the GC modifier.
1. New
						section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and
						print only pursuant to Government Code section
						11340.9(g)
						(Register 2013, No. 39).
2. Amendment filed 11-6-2018; operative
						1-1-2019. Submitted to OAL for filing and printing only pursuant to Government
						Code section
						11340.9(g)
						(Register 2018, No. 45).
Note: Authority: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  5307.1 and
						  5307.11, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.18.12 - Anesthesia and Medical/Surgical Service Provided by the Same Physician

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) For services
					 rendered before March 1, 2017, conscious sedation codes 99143 to 99145 may be
					 billed as long as the procedure it is billed with is not listed in Appendix G
					 of CPT (Summary of Codes that Include Moderate Conscious Sedation.)
(b) For services rendered before March 1,
					 2017, when a second physician other than the health care professional
					 performing the diagnostic or therapeutic services provides moderate sedation in
					 the facility setting for the procedures listed in Appendix G, the second
					 physician may bill 99148 to 99150. When these services are performed by the
					 second physician in the nonfacility setting, CPT codes 99148 to 99150 are not
					 to be reported.
(c) If the
					 anesthesiologist or CRNA provides anesthesia for diagnostic or therapeutic
					 nerve blocks or injections and a different provider performs the block or
					 injection, then the anesthesiologist or CRNA may report the anesthesia service
					 using CPT code 01991. The service must meet the criteria for monitored
					 anesthesia care. If the anesthesiologist or CRNA provides both the anesthesia
					 service and the block or injection, then the anesthesiologist or CRNA may
					 report the anesthesia service using the conscious sedation code and the
					 injection or block. However, the anesthesia service must meet the requirements
					 for conscious sedation and if a lower level complexity anesthesia service is
					 provided, then the conscious sedation code shall not be reported.
(d) If the physician performing the medical
					 or surgical procedure also provides a level of anesthesia lower in intensity
					 than moderate or conscious sedation, such as a local or topical anesthesia,
					 then the conscious sedation code shall not be reported and no payment shall be
					 allowed. There is no CPT code for the performance of local anesthesia as
					 payment for this service is considered to be bundled into the payment for the
					 underlying medical or surgical service.
1. New
						section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and
						print only pursuant to Government Code section
						11340.9(g)
						(Register 2013, No. 39).
2. Amendment of subsections (a) and (b)
						filed 7-18-2017; operative 3-1-2017. Submitted to OAL as a file and print only
						pursuant to Labor Code section
						5307.1(g)(2)
						(Register 2017, No. 29).
Note: Authority: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  5307.1 and
						  5307.11, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.19.1 - Table A

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For anesthesia services rendered on or after January 1,
						2019, Table A contains the anesthesia conversion factor adjusted by Medicare
						locality GPCIs and anesthesia shares, which are incorporated by reference, by
						date of service. Table A will be updated by Administrative Director Order and
						will be made available at
http://www.dir.ca.gov/dwc/OMFS9904.htm
,
						or upon request to the Administrative Director at:
DIVISION OF WORKERS' COMPENSATION (ATTENTION:
						OMFS)
P.O. BOX 420603
SAN FRANCISCO, CA 94142
1. New
						section filed 11-6-2018; operative 1-1-2019. Submitted to OAL for filing and
						printing only pursuant to Government Code section
						11340.9(g)
						(Register 2018, No. 45).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  5307.1 and
						  5307.11, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.21 - Definitions for Inpatient Hospital Fee Schedule

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) "Average length of stay" means the
					 geometric mean length of stay for a diagnosis-related group assigned by
					 CMS.
(b) "Capital outlier factor"
					 means for discharges occurring after January 1, 2004 and before January 1,
					 2008, the fixed loss cost outlier threshold x capital wage index x large urban
					 add-on x (capital cost-to-charge ratio/total cost-to-charge ratio).
For discharges on or after January 1, 2008, "Capital
						outlier factor" means fixed loss cost outlier threshold x capital wage index x
						(capital cost-to-charge ratio/total cost-to-charge ratio) as modified by Title
						42, Code of Federal Regulations, Section
						412.316(b), as it
						is in effect on November 11, 2003, amended October 1, 2004, amended October 1,
						2006, and amended as of October 1, 2007, which document is hereby incorporated
						by reference and will be made available upon request to the Administrative
						Director.
(1) The capital wage index,
					 also referred to as the capital geographic factor (GAF), is specified in the
					 Federal Register notices announcing revisions in the Medicare payment rates.
					 See Section
					 9789.25(b) for the
					 Federal Register reference that contains the capital wage index value for a
					 given discharge.
(2) For discharges
					 occurring before January 1, 2008, the "large urban add-on" is an additional 3%
					 of what would otherwise be payable to the hospital, and the large urban add-on
					 is eliminated for discharges occurring on or after January 1, 2008, pursuant to
					 Title 42, Code of Federal Regulations, Section
					 412.316(b). See
					 Section 9789.25(a) for the
					 Federal Regulation reference to the large urban add-on.
(3) "Fixed loss cost outlier threshold" means
					 the Medicare fixed loss cost outlier threshold for inpatient admissions. The
					 threshold is specified in the Federal Register notices announcing revisions in
					 the Medicare payment rates. See Section
					 9789.25(b) for the
					 Federal Register reference that defines the fixed loss cost outlier threshold
					 by date of discharge.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.23 - Hospital Cost to Charge Ratios, Hospital Specific Outliers, and Hospital Composite Factors

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For discharges on or after January 1, 2004, hospital cost
						to charge ratios, hospital specific outliers, and hospital composite factors by
						date of discharge, are incorporated by reference, and are available at
http://www.dir.ca.gov/dwc/OMFS9904.htm#4
,
						or upon request to the Administrative Director at:
DIVISION OF WORKERS' COMPENSATION (ATTENTION:
						OMFS)
P.O. BOX 420603
SAN FRANCISCO, CA 94142
Full Payment Impact File (impfile04zip) at
						http://www.cms.gov/providers/hipps/ippsputs.asp (Section
						9789.23 reflects the modifications
						of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003,
						Public Law
						108-173,
						sections
						402,
						402 and
						502, section
						3133 of the Affordable Care Act,
						and section
						1886(r) of the
						Social Security Act, which documents are hereby incorporated by reference and
						will be made available upon request to the Administrative Director.)
Record Layout at
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html?redirect=/AcuteInpatientPPS/
.
Composite Rate (in italics) reflects Sole Community
						Hospital adjustment. See Section
						9789.25(a) for the
						Code of Federal Regulations reference for the effective date, revisions, and
						amendments by date of discharge, and see Section
						9789.25(c) for
						references to the Payment Impact File by date of discharge.
1. New
						section filed 1-2-2004 as an emergency; operative 1-2-2004 (Register 2004, No.
						2). A Certificate of Compliance must be transmitted to OAL by 5-3-2004 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 1-2-2004 order, including
						amendment of section heading and repealer and new section, transmitted to OAL
						4-30-2004 and filed 6-15-2004 (Register 2004, No. 25).
3. Amendment
						filed 3-13-2013; operative 3-15-2013. Submitted to OAL for filing and printing
						only pursuant to Labor Code section
						5307.1(g)(2)
						(Register 2013, No. 11).
4. Amendment filed 2-4-2015; operative
						3-5-2015. Submitted to OAL for printing only pursuant to Government Code
						section
						11340.9
						(Register 2015, No. 6).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.1,
						  5307.3 and
						  5318, Labor
						  Code. Reference: Sections
						  4600,
						  4603.2,
						  5307.1 and
						  5318, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.24 - Diagnostic Related Groups, Relative Weights, Geometric Mean Length of Stay

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For discharges on or after January 1, 2004, diagnostic
						related groups, relative weights, and geometric mean length of stay by date of
						discharge, are incorporated by reference, and are available at
http://www.dir.ca.gov/dwc/OMFS9904.htm#4
,
						or upon request to the Administrative Director at:
DIVISION OF WORKERS' COMPENSATION (ATTENTION:
						OMFS)
P.O. BOX 420603
SAN FRANCISCO, CA 94142
1. New
						section filed 1-2-2004 as an emergency; operative 1-2-2004 (Register 2004, No.
						2). A Certificate of Compliance must be transmitted to OAL by 5-3-2004 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 1-2-2004 order transmitted
						to OAL 4-30-2004 and filed 6-15-2004 (Register 2004, No. 25).
3.
						Repealer and new section filed 3-13-2013; operative 3-15-2013. Submitted to OAL
						for filing and printing only pursuant to Labor Code section
						5307.1(g)(2)
						(Register 2013, No. 11).
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.34 - Table A

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For services rendered on or after January 1, 2004, the
						"adjusted conversion factor" and wage index values are incorporated by
						reference, for services rendered by hospital outpatient departments not listed
						in Section 9789.35 (Table B) and services
						rendered by ambulatory surgical centers on or after the date the Administrative
						Director Order becomes effective, and are available at
http://www.dir.ca.gov/dwc/OMFS9904.htm
,
						or upon request to the Administrative Director at:
DIVISION OF WORKERS' COMPENSATION (ATTENTION:
						OMFS)
P.O. BOX 420603
SAN FRANCISCO, CA 94142
1. New
						section filed 1-2-2004 as an emergency; operative 1-2-2004 (Register 2004, No.
						2). A Certificate of Compliance must be transmitted to OAL by 5-3-2004 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 1-2-2004 order, including
						amendment of section, transmitted to OAL 4-30-2004 and filed 6-15-2004
						(Register 2004, No. 25).
3. Repealer and new section filed
						3-29-2013; operative 4-1-2013 pursuant to Labor Code section
						5307.1(g)(2).
						Submitted to OAL for filing and printing only pursuant to Labor Code section
						5307.1(g)(2)
						(Register 2013, No. 13).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  4603.2 and
						  5307.1, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.35 - Table B

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For services rendered on or after January 1, 2004, the
						"adjusted conversion factor" and hospital-specific wage index values for listed
						hospital outpatient departments, are incorporated by reference, for services
						rendered on or after the date the Administrative Director Order becomes
						effective, and are available at
http://www.dir.ca.gov/dwc/OMFS9904.htm
,
						or upon request to the Administrative Director at:
DIVISION OF WORKERS' COMPENSATION (ATTENTION:
						OMFS)
P.O. BOX 420603
SAN FRANCISCO, CA 94142.
1. New
						section filed 1-2-2004 as an emergency; operative 1-2-2004 (Register 2004, No.
						2). A Certificate of Compliance must be transmitted to OAL by 5-3-2004 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 1-2-2004 order, including
						amendment, transmitted to OAL 4-30-2004 and filed 6-15-2004 (Register 2004, No.
						25).
3. Repealer and new section filed 3-29-2013; operative 4-1-2013
						pursuant to Labor Code section
						5307.1(g)(2).
						Submitted to OAL for filing and printing only pursuant to Labor Code section
						5307.1(g)(2)
						(Register 2013, No. 13).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  4603.2 and
						  5307.1, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.36 - Update of Rules to Reflect Changes in the Medicare Payment System

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Sections
						9789.30 through
						9789.39 shall be adjusted to
						conform to any relevant changes in the Medicare payment schedule, including
						mid-year changes, no later than 60 days after the effective date of those
						changes. Updates shall be posted on the Division of Workers' Compensation
						webpage at
http://www.dir.ca.gov/dwc/dwc_home_page.htm
.
						The annual updates to the Hospital Outpatient Departments and Ambulatory
						Surgical Centers Fee Schedule shall be effective every year on March
						1.
1. New
						section filed 1-2-2004 as an emergency; operative 1-2-2004 (Register 2004, No.
						2). A Certificate of Compliance must be transmitted to OAL by 5-3-2004 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 1-2-2004 order, including
						amendment of section, transmitted to OAL 4-30-2004 and filed 6-15-2004
						(Register 2004, No. 25).
3. Amendment filed 12-27-2012; operative
						1-1-2013 as a file and print only pursuant to Government Code section
						11340.9(g)
						(Register 2012, No. 52).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  4603.2 and
						  5307.1, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.38 - Appendix X

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The federal regulations as incorporated by reference
						and/or referred to in Sections
						9789.30 through
						9789.37 are set forth below in
						numerical order. See Section
						9789.39(a), (b),
						for the Code of Federal Regulations reference for effective date, revisions,
						and amendments by date of service.
42
						C.F.R. §
												419.2
Basis of payment.
(a) Unit of payment. Under the hospital
					 outpatient prospective payment system, predetermined amounts are paid for
					 designated services furnished to Medicare beneficiaries. These services are
					 identified by codes established under the Centers for Medicare & Medicaid
					 Services Common Procedure Coding System (HCPCS). The prospective payment rate
					 for each service or procedure for which payment is allowed under the hospital
					 outpatient prospective payment system is determined according to the
					 methodology described in subpart C of this part. The manner in which the
					 Medicare payment amount and the beneficiary copayment amount for each service
					 or procedure are determined is described in subpart D of this part.
(b) Determination of hospital outpatient
					 prospective payment rates: Included costs. The prospective payment system
					 establishes a national payment rate, standardized for geographic wage
					 differences, that includes operating and capital-related costs that are
					 directly related and integral to performing a procedure or furnishing a service
					 on an outpatient basis. In general, these costs include, but are not limited to
(1) Use of an operating suite, procedure
					 room, or treatment room;
(2) Use of
					 recovery room;
(3) Use of an
					 observation bed;
(4) Anesthesia,
					 certain drugs, biologicals, and other pharmaceuticals; medical and surgical
					 supplies and equipment; surgical dressings; and devices used for external
					 reduction of fractures and dislocations;
(5) Supplies and equipment for administering
					 and monitoring anesthesia or sedation;
(6) Intraocular lenses (IOLs);
(7) Incidental services such a
					 venipuncture;
(8) Capital-related
					 costs;
(9) Implantable items used
					 in connection with diagnostic x-ray tests, diagnostic laboratory tests, and
					 other diagnostic tests;
(10)
					 Durable medical equipment that is implantable;
(11) Implantable prosthetic devices (other
					 than dental) which replace all or part of an internal body organ (including
					 colostomy bags and supplies directly related to colostomy care), including
					 replacement of these devices; and;
(12) Costs incurred to procure donor tissue
					 other than corneal tissue.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.40 - Pharmacy

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The maximum
					 reasonable fee for pharmaceuticals and pharmacy services rendered after January
					 1, 2004 is 100% of the reimbursement prescribed in the relevant Medi-Cal
					 payment system, including the Medi-Cal professional fee for dispensing.
					 Medi-Cal rates will be made available on the Division of Workers'
					 Compensation's Internet Website (
http://www.dir.ca.gov/DWC/dwc_home_page.htm
)
					 or upon request to the Administrative Director at:
DIVISION OF WORKERS' COMPENSATION
(ATTENTION: OMFS -- PHARMACY)
P.O. BOX 420603
SAN FRANCISCO, CA 94142.
(b) For a pharmacy service or drug that is
					 not covered by a Medi-Cal payment system, the maximum reasonable fee paid shall
					 not exceed the drug cost portion of the fee determined in accordance with this
					 subdivision, plus $7.25 professional fee for dispensing or $8.00 if the patient
					 is in a skilled nursing facility or in an intermediate care facility. The
					 maximum fee shall include only a single professional dispensing fee for
					 dispensing for each dispensing of a drug.
(1)
					 If the National Drug Code for the drug product as dispensed is not in the
					 Medi-Cal database, and the National Drug Code for the underlying drug product
					 from the original labeler appears in the Medi-Cal database, then the maximum
					 fee shall be the drug cost portion of the reimbursement allowed pursuant to
					 section
					 14105.45
					 of the Welfare and Institutions Code using the National Drug Code for the
					 underlying drug product from the original labeler as it appears in the Medi-Cal
					 database, calculated on a per unit basis, plus the professional fee allowed by
					 subdivision (b) of this section.
(2) If the National Drug Code for the drug
					 product as dispensed is not in the Medi-Cal database and the National Drug Code
					 for the underlying drug product from the original labeler is not in the
					 Medi-Cal database, then the maximum fee shall be 83 percent of the average
					 wholesale price of the lowest priced therapeutically equivalent drug,
					 calculated on a per unit basis, plus the professional fee allowed by
					 subdivision (b) of this section.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.50 - Pathology and Laboratory

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Effective for services after January 1,
					 2004, the maximum reasonable fees for pathology and laboratory services shall
					 not exceed one hundred twenty (120) percent of the rate for the same procedure
					 code in the CMS' Clinical Diagnostic Laboratory Fee Schedule, as established by
					 Sections 1833 and
					 1834 of the Social Security Act
					 (42 U.S.C. §§
												1395
l
and 1395m) and
					 applicable to California. The Clinical Diagnostic Laboratory Fee Schedule,
					 which can be found on the CMS Internet Website (
http://www.cms.gov/Medicare/Medicare-Fee-For-Service-Payment/Clinicallabfeesched/index.html
)
					 is incorporated by reference and will be made available on the Division of
					 Workers' Compensation's Internet Website (
http://www.dir.ca.gov/DWC/dwc_home_page.htm
)
					 or upon request to the Administrative Director at:
DIVISION OF WORKERS' COMPENSATION (ATTENTION:
						OMFS)
P.O. BOX 420603
SAN FRANCISCO, CA 94142.
(b) The following procedures in the Special
					 Services and Reports section of the OMFS 2003 will not be valid for services
					 rendered after January 1, 2004: CPT Codes 99000, 99001, 99017, 99019, 99020,
					 99021, 99026, and 99027.
1. New
						section filed 1-2-2004 as an emergency; operative 1-2-2004 (Register 2004, No.
						2). A Certificate of Compliance must be transmitted to OAL by 5-3-2004 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 1-2-2004 order, including
						new subsection (c), transmitted to OAL 4-30-2004 and filed 6-15-2004 (Register
						2004, No. 25).
3. Amendment of subsection (a) and repealer of
						subsection (c) filed 2-4-2015; operative 3-5-2015. Submitted to OAL for
						printing only pursuant to Government Code section
						11340.9
						(Register 2015, No. 6).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  4603.2 and
						  5307.1, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.60 - Durable Medical Equipment, Prosthetics, Orthotics, Supplies

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) For services,
					 equipment, or goods provided after January 1, 2004, the maximum reasonable
					 reimbursement for durable medical equipment, supplies and materials, orthotics,
					 prosthetics, and miscellaneous supplies and services shall not exceed one
					 hundred twenty (120) percent of the rate set forth in the CMS' Durable Medical
					 Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) Fee Schedule, as
					 established by Section
					 1834 of the Social Security Act
					 (42 U.S.C. §
												1395m) and applicable to California. The
					 DMEPOS Fee Schedule, which can be found on the CMS Internet Website (
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html
)
					 is incorporated by reference and will be made available on the Division of
					 Workers' Compensation's Internet Website (
http://www.dir.ca.gov/DWC/dwc_home_page.htm
)
					 or upon request to the Administrative Director at:
DIVISION OF WORKERS' COMPENSATION (ATTENTION:
						OMFS)
P.O. BOX 420603
SAN FRANCISCO, CA 94142.
(b) The following procedures in the Special
					 Services and Reports section of the OMFS 2003 will not be valid for services
					 rendered after January 1, 2004: CPT Code 99002.
1. New
						section filed 1-2-2004 as an emergency; operative 1-2-2004 (Register 2004, No.
						2). A Certificate of Compliance must be transmitted to OAL by 5-3-2004 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 1-2-2004 order, including
						amendment of subsection (b) and new subsection (c), transmitted to OAL
						4-30-2004 and filed 6-15-2004 (Register 2004, No. 25).
3. Amendment
						of subsection (a) and repealer of subsection (c) filed 2-4-2015; operative
						3-5-2015. Submitted to OAL for printing only pursuant to Government Code
						section
						11340.9
						(Register 2015, No. 6).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  4603.2 and
						  5307.1, Labor
						  Code.