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 9789.12.4 - "by Report" - Reimbursement for Unlisted Procedures/Procedures Lacking RBRVUs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An
					 unlisted procedure shall be billed using the appropriate unlisted procedure
					 code from the CPT. The procedure shall be billed by report (report not
					 separately reimbursable), justifying that the service was reasonable and
					 necessary to cure or relieve from the effects of the industrial injury or
					 illness. Pertinent information should include an adequate definition or
					 description of the nature, extent, and need for the procedure, and the time,
					 effort and equipment necessary to provide the service.
(b)
(1) In
					 accordance with section
					 9789.12.3, when procedures with
					 status indicator codes C, N, or R, do not have RVUs assigned under the CMS'
					 National Physician Fee Schedule Relative Value File, these services shall be
					 billed by report, justifying that the service was reasonable and necessary to
					 cure or relieve from the effects of the industrial injury or illness. Pertinent
					 information should include an adequate definition or description of the nature,
					 extent, and need for the procedure, and the time, effort and equipment
					 necessary to provide the service.
(2) CPT codes that:
1) appear in the CMS' National Physician Fee
					 Schedule Relative Value File, and
2) do not have an RVU assigned for the
					 service, and
3) that are payable
					 under a fee schedule contained in section
					 9789.30 -
					 9789.70, are not payable under the
					 physician fee schedule on a "By Report" basis.
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 9789.12.5 - Conversion Factors

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The conversion factors to be used for determining maximum reasonable fees are
					 set forth in section
					 9789.19, by date of
					 service.
(b)
(1) Commencing January 1, 2014, there shall
					 be a four-year transition between:
"OMFS Budget Neutral CF": the estimated aggregate maximum
						allowable amount under the official medical fee schedule for physician services
						prior to January 1, 2014, and
"120% RBRVS 2012 CF": the maximum allowable amount based
						on the resource-based relative value scale at 120 percent of the Medicare
						conversion factor in effect in July 2012.
(2) During the transition, the conversion
					 factors before adjustment shall be as follows:
Type of
								Service
OMFS Budget- Neutral
								CF
120% 2012 Medicare
2014
								(75 Percent OMFS/25 Percent 120 % Medicare)
2015 (50
								Percent OMFS/50 Percent 120 % Medicare)
2016 (25
								Percent OMFS/75 Percent 120 % Medicare)
2017 (120%
								Medicare)
Anesthesia
34.5903
25.6896
32.3651
30.1400
27.9148
25.6896
Surgery
55.6849
40.8451
51.9750
48.2650
44.5551
40.8451
Radiology
52.9434
40.8451
49.9188
46.8943
43.8697
40.8451
All other
								services
34.4566
40.8451
36.0537
37.6509
39.2480
40.8451
(3) The conversion factors specified in
					 subdivision (b)(2) shall be adjusted by the cumulative changes in MEI and the
					 Relative Value Scale Adjustment Factor, if any, between 2012 and each
					 transition year. See section
					 9789.19 for annual and cumulative
					 MEI, and Relative Value Scale Adjustment Factor, by date of service.
(4)
(A)
					 During years 2014 through 2016:
(1) The
					 anesthesia conversion factor shall be applied to CPT codes in the Anesthesia
					 section of the CPT;
(2) The surgery
					 conversion factor shall be applied to CPT codes in the Surgery section of the
					 CPT;
(3) The radiology conversion
					 factor shall be applied to CPT codes in the Radiology section of the
					 CPT;
(4) The "other services"
					 conversion factor shall be applied to CPT codes in the Evaluation and
					 Management, Medicine, and Pathology and Laboratory sections of the CPT, to the
					 extent the services are payable under this fee schedule.
(B) In 2017, and thereafter, there will be
					 two conversion factors: Anesthesia and Other
					 Services.
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 9789.12.7 - CMS' National Physician Fee Schedule Relative Value File / Relative Value Units (RVUs)

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The National Physician Fee Schedule Relative Value File
						which is published on the CMS website shall be utilized to determine the
						maximum reasonable fees. See section
						9789.19 for Relative Value File by
						date of 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 9789.12.10 - Coding; Current Procedural Terminology, Fourth Edition

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The coding, modifiers, guidelines,
					 appendices and all other provisions of
Current Procedural
					 Terminology
©, Fourth Edition
					 ("
CPT
"), published by the American Medical Association are
					 applicable to the bills submitted for physician and non-physician practitioner
					 services, except:
(1) any provision in the
					 Physician Fee Schedule that conflicts with a provision in
CPT
will take precedence over the
CPT
, and
(2) as otherwise specified in regulation. See
					 section 9789.19 for the version of the CPT
					 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 9789.12.11 - Evaluation and Management: Coding - New Patient; Established Patient; Documentation

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) For
					 purposes of workers' compensation billing, the following definitions of "new
					 patient" and "established patient" will be used instead of the CPT definitions:
(1) A "new patient" is one who is new to the
					 physician or medical group or an established patient with a new industrial
					 injury or illness. Only one new patient visit is reimbursable to a single
					 physician or medical group per specialty for evaluation of the same patient
					 relating to the same incident, injury or illness.
(2) An "established patient" is a patient who
					 has been seen previously for the same industrial injury or illness by the
					 physician or medical group.
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 9789.12.12 - Consultation Services Coding - Use of Visit Codes

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Maximum
					 fees for physicians and qualified non-physician practitioners performing
					 consultation services shall be determined utilizing the appropriate RVU for a
					 patient evaluation and management visit and the RVU(s) for prolonged service
					 codes if warranted under CPT guidelines. Physicians and qualified non-physician
					 practitioners shall code consultation visits as patient evaluation and
					 management visits utilizing the CPT Evaluation and Management codes that
					 represent where the visit occurs and that correspond to the level of the visit
					 performed. CPT consultation codes shall not be utilized.
(1) In the inpatient hospital setting and the
					 nursing facility setting consulting physicians (and qualified non-physician
					 practitioners where permitted) who perform an initial evaluation may bill the
					 initial hospital inpatient or observation care codes (99221 -- 99223) or
					 nursing facility care codes (99304 -- 99306).
Follow-up consultation visits in the inpatient hospital
						setting shall be billed as subsequent hospital inpatient or observation care
						visits (99231 -- 99233) and subsequent nursing facility care visits (99307 --
						99310.)
(2) In the office
					 or other outpatient setting where a consultation / evaluation is performed,
					 physicians and qualified non-physician practitioners shall use the CPT visit
					 codes (99202 -- 99215) that correspond to the level of the visit and based upon
					 whether the patient is a new or established patient to that physician, as
					 defined in section
					 9789.12.11.
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 9789.12.14 - California Specific Codes

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Physicians and non-physician practitioners shall use the
						"California Specific Codes" listed below. Maximum reasonable fees for services
						performed by physicians and non-physician practitioners within their scope of
						practice shall be no more than the fee listed in section
						9789.19, by date of service. The
						fees shall be updated annually in accordance with the Medicare Economic
						Index.
CA
								Code
Procedure
WC001
Doctor's First Report of Occupational
								Illness or Injury (Form 5021) (Section
								9789.14(a)(1))
WC002
Treating Physician's Progress Report
								(PR-2 or narrative equivalent in accordance with §
														9785) (Section
								9789.14(b)(1))
WC003
Primary Treating Physician's
								Permanent and Stationary Report (Form PR-3) (Section
								9789.14(b)(2))
WC004
Primary Treating Physician's
								Permanent and Stationary Report (Form PR-4) (Section
								9789.14(b)(3))
WC005
Psychiatric Report requested by the
								WCAB or the Administrative Director, other than medical-legal report. Use
								modifier -32 (Section
								9789.14(b)(4))
WC006
[Reserved]
WC007
Consultation Reports Requested by the
								Workers' Compensation Appeals Board or the Administrative Director (Use
								modifier -32) Consultation Reports requested by the QME or AME in the context
								of a medical-legal evaluation (Section
								9789.14(b)(5)).
								(Use modifier -30)
WC008
Chart Notes (Section
								9789.14(c))
WC009
Duplicate Reports (Section
								9789.14(d))
WC010
Duplication of X-Ray
WC011
Duplication of Scan
WC012
Missed Appointments. This code is
								designated for communication only. It does not imply that compensation is
								owed.
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 9789.12.15 - California Specific Modifier

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The following modifier is to be appended to the
						applicable CPT Code or California Specific code in addition to any applicable
						CPT modifier.
-30
Consultation Service During
								Medical-Legal Evaluation:
Services or procedures performed by a
								consultant at the request of a QME or AME in the context of a medical-legal
								evaluation where those services are paid under the Physician Fee Schedule.
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 9789.13.1 - Supplies

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Separate
					 payment for routinely bundled supplies is not allowed.
(b) See section
					 9789.13.2 regarding payment for
					 physician-administered drugs/biological/vaccines/blood products.
(c) Splints and casting supplies are payable
					 separately in addition to payment for the procedure for applying the splint or
					 cast, performed in a physician's office. See section
					 9789.19 for the splint and cast
					 HCPCS codes and maximum payment amounts, by date of service. For services on or
					 after April 1, 2014, maximum fees for splints and casting supplies are
					 determined by the Durable Medical Equipment, Prosthetics, Orthotics, Supplies
					 fee schedule.
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 subsection (c) filed
						3-23-2016; operative 1-1-2016 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 2016, No. 13).
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 9789.13.2 - Physician-Administered Drugs, Biologicals, Vaccines, Blood Products

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Physician-administered drugs,
					 biologicals, vaccines, or blood products are separately payable.
(1) Vaccines shall be reported using the NDC
					 and CPT-codes for the vaccine. Other physician-administered drugs, biological
					 and blood products shall be reported using the NDC and J-codes assigned to the
					 product.
(2) The maximum
					 reimbursement shall be determined using the "Basic Rate" for the HCPCS code
					 contained on the Medi-Cal Rates file for the date of service. The Medi-Cal fee
					 schedule reimburses drug products, vaccines and immunizations at the Medicare
					 rate of reimbursement when established and published by the Centers for
					 Medicare & Medicaid Services (CMS) or the Medi-Cal pharmacy rate of
					 reimbursement when the Medicare rate is not available. The Medicare rate is
					 currently defined as average sales price (ASP) plus 6 percent. The pharmacy
					 rate is currently defined as the lower of (1) the average wholesale price (AWP)
					 minus 17 percent; (2) the federal upper limit (FUL); or (3) the maximum
					 allowable ingredient cost (MAIC).
(3) The "Basic Rate" price listed on the
					 Medi-Cal rates page of the Medi-Cal website for each physician-administered
					 drug includes an injection administration fee of $4.46. This injection
					 administration fee should be subtracted from the published rate because payment
					 for the injection administration fee will be determined under the RBRVS. See
					 section 9789.19 for a link to the
					 Department of Health Care Services' Medi-Cal rates file.
(4) For a physician-administered drug,
					 biological, vaccine or blood product not contained in the Medi-Cal Rates file
					 referenced in subdivision (a)(2), the maximum reimbursement is the amount
					 prescribed in the Medi-Cal Pharmacy Fee Schedule as adopted by the Division of
					 Workers' Compensation in section
					 9789.40 and posted on the Division
					 website as the Pharmaceutical Fee Schedule. See section
					 9789.19 for a link to the Division
					 of Workers' Compensation Pharmaceutical Fee Schedule.
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 9789.13.3 - Physician-Dispensed Drugs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The maximum reimbursement for physician-dispensed drugs
						is determined pursuant to the Pharmaceutical Fee Schedule set forth in section
						9789.40 and pursuant to the
						provisions of Labor Code section
						5307.1.
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 9789.14 - Reimbursement for Reports, Duplicate Reports, Chart Notes

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
This section governs reimbursement of all reports other
						than those which are payable under the medical-legal fee schedule, found at
						section 9793 et seq.
(a) Treatment Reports Not Separately
					 Reimbursable.
The following treatment reports are not separately
						reimbursable as the appropriate fee is included within the underlying
						Evaluation and Management service, Physical Therapy Evaluation service or
						Occupational Therapy Evaluation service for an office visit:
(1) Doctor's First Report of Occupational
					 Illness or Injury (Form 5021) issued in accordance with section
					 9785(e). Use Code
					 WC001;
(2) Consultation Reports,
					 except as specified in subdivision (b)(5).
(3) Report by a secondary physician to the
					 primary treating physician.
(4)
					 Physician's Return-to-Work & Voucher Report (DWC-AD 10133.36) issued in
					 accordance with section
					 9785 subdivision (i) (reimbursement
					 is bundled into payment for PR-3 or PR-4).
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 9789.15.1 - Non-Physician Practitioner (NPP) - Payment Methodology

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) For purposes of this section, NPP
					 services means services provided by physician assistants, nurse practitioners,
					 clinical nurse specialists, and clinical social workers.
(b) Except for clinical social workers,
					 maximum fees for NPP services shall be 85 percent of what a physician is paid
					 under the Official Medical Fee Schedule - Physician Fee Schedule. Maximum fees
					 for clinical social workers shall be 75 percent of what a physician is paid
					 under the Official Medical Fee Schedule- Physician Fee Schedule. Maximum fees
					 for NPP assistant-at-surgery services are set according to Section
					 9789.15.1(c).
					 Maximum fees for services provided by NPPs employed by the physician that are
					 incident to the physician service shall be at 100 percent of the physician fee
					 schedule amount as though the physician personally performed the
					 services.
(c) When a NPP actively
					 assists a physician in performing a surgical procedure and furnishes more than
					 just ancillary services, the NPP's services are eligible for payment as
					 assistant-at-surgery services. Maximum fees for covered NPP
					 assistant-at-surgery services shall be 85 percent of what a physician is paid
					 under the Official Medical Fee Schedule -- Physician Fee Schedule. Since
					 physicians are paid at 16 percent of the surgical payment amount for
					 assistant-at-surgery services, the actual payment amount that NPPs receive for
					 assistant-at-surgery services is 13.6 percent of the amount paid to physicians.
					 The AS modifier must be reported when billing NPP assistant-at-surgery
					 services.
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 9789.15.2 - Non-Physician Practitioner (NPP) - "Incident to" Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Non-institutional Setting.
For purposes of this section a non-institutional setting
						means all settings other than a hospital or skilled nursing facility.
(1) Services that are furnished incident to a
					 physician's are commonly included in the physician's bills, and for which no
					 separate payment is made. Diagnostic tests and pneumococcal, influenza, and
					 hepatitis B vaccines need not also meet the incident to requirement in this
					 section.
(2) NPPs may provide
					 services without direct physician supervision and bill directly for these
					 services. When their services are provided under direct physician supervision,
					 their services may be covered as incident to services, in which case the
					 incident to requirements would apply.
(3) To be covered incident to the services of
					 a physician, services must be:
(A) An
					 integral, although incidental, part of the physician's professional
					 service;
(B) Commonly rendered
					 without charge or included in the physician's bill;
(C) Of a type that are commonly furnished in
					 physician's offices or clinics;
(D)
					 Furnished by the physician or by auxiliary personnel under the physician's
					 direct supervision.
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 9789.15.3 - Qualified Non-Physician Anesthetist Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) This subsection applies to certified
					 registered nurse anesthetists (CRNAs) and certified anesthesiologist assistants
					 (AAs). The term "qualified non-physician anesthetist" refers to both CRNAs and
					 AAs.
(b) The maximum fee for
					 anesthesia services furnished by qualified non-physician anesthetists is the
					 fee determined by this section and section
					 9789.18.1.
(c) Anesthesia time means the time during
					 which a qualified non-physician anesthetist is present with the patient. It
					 starts when the qualified non-physician anesthetist begins to prepare the
					 patient for anesthesia services in the operating room or an equivalent area and
					 ends when the qualified non-physician anesthetist 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 qualified non-physician anesthetist can add blocks of time
					 around an interruption in anesthesia time as long as the qualified
					 non-physician anesthetist is furnishing continuous anesthesia care within the
					 time periods around the interruption.
(d) The following modifiers are used when
					 billing for anesthesia services:
(1) QX --
					 Qualified non-physician anesthetist with medical direction by a
					 physician.
(2) QZ -- CRNA without
					 medical direction by a physician.
(3) QS -- Monitored anesthesiology care
					 services (can be billed by a qualified non-physician anesthetist or a
					 physician).
(4) QY -- Medical
					 direction of one qualified non-physician anesthetist by an
					 anesthesiologist.
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 9789.15.4 - Physical Medicine/Chiropractic/Acupuncture Multiple Procedure Payment Reduction; Pre-Authorization for Specified Procedure/Modality Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
(1) The Medicare Multiple Procedure Payment
					 Reduction ("MPPR") for "Always Therapy" Codes shall be applied when more than
					 one of the following codes is billed on the same day: codes on the Medicare
					 "Always Therapy" list, acupuncture codes, chiropractic manipulation
					 codes.
(2) Many therapy services
					 are time-based codes, i.e., multiple units may be billed for a single
					 procedure. The MPPR applies to the Practice Expense ("PE") payment when more
					 than one unit or procedure is provided to the same patient on the same day,
					 i.e., the MPPR applies to multiple units as well as multiple procedures. Full
					 payment is made for the unit or procedure with the highest PE payment. Full
					 payment is made for the work and malpractice components and 50 percent payment
					 is made for the PE for subsequent units and procedures, furnished to the same
					 patient on the same day.
(3) For
					 therapy services furnished by a group practice or "incident to" a physician's
					 service, the MPPR applies to all services furnished to a patient on the same
					 day, regardless of whether the services are provided in one therapy discipline
					 or multiple disciplines, for example, physical therapy, occupational therapy,
					 or speech-language pathology.
(4)
					 The MPPR applies to acupuncture codes and chiropractic manipulation codes and
					 to the procedures listed in the "Separately Payable Always Therapy Services
					 Subject to the Multiple Procedure Payment Reduction (MPPR)" file of the
					 Medicare Physician Fee Schedule Final Rule. The listed procedures will also
					 have a Multiple Procedure value of "5" on the National Physician Fee Schedule
					 Relative Value File.
(5) See
					 section 9789.19 for the location of the
					 list of codes on the Medicare "Always Therapy" code list, 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 9789.15.5 - Ophthalmology Multiple Procedure Reduction

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Multiple Procedure Payment Reduction
					 (MPPR) on ophthalmology procedures applies when multiple services are furnished
					 to the same patient on the same day. The MPPRs apply to Technical Component
					 (TC)-only services, and to the TC of global services. Full payment is made for
					 the TC service with the highest payment. Payment is made at 80 percent for
					 subsequent TC services furnished by the same physician (or by multiple
					 physicians in the same group practice, i.e., same Group National Provider
					 Identifier (NPI)) to the same patient on the same day. The MPPR does not apply
					 to professional component (PC) services. See section
					 9789.19 for the location of the
					 list of codes subject to the MPPR on ophthalmology procedures, by date of
					 service.
(b) For services subject
					 to both the multiple procedure payment reduction and the OPPS cap on imaging,
					 the MPPR shall be applied first, then the reduced amount will be compared with
					 the OPPS cap, and the lower amount shall be used.
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 9789.15.6 - Diagnostic Cardiovascular Procedures - Multiple Procedure Reduction

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Multiple
					 Procedure Payment Reduction (MPPR) on diagnostic cardiovascular procedures
					 applies when multiple services are furnished to the same patient on the same
					 day. The MPPR applies to Technical Component (TC)-only services, and to the TC
					 of global services. Full payment is made for the TC service with the highest
					 payment. Payment is made at 75 percent for subsequent TC services furnished by
					 the same physician (or by multiple physicians in the same group practice, i.e.,
					 same Group National Provider Identifier (NPI)) to the same patient on the same
					 day. The MPPR does not apply to professional component (PC) services. See
					 section 9789.19 for the location of the
					 list of codes subject to the MPPR on diagnostic cardiovascular procedures, by
					 date of service.
(b) For services
					 subject to both the multiple procedure payment reduction and the OPPS cap on
					 imaging, the MPPR shall be applied first, then the reduced amount will be
					 compared with the OPPS cap, and the lower amount shall be used.
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 9789.16.1 - Surgery - Global Fee

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Global Surgical Package.
A global surgical package refers to a payment policy of
						bundling payment for the various services associated with a surgical procedure
						into a single payment covering the operation and these other services.
(1) Definition of a Global Surgical Package.
					 The National Physician Fee Schedule Relative Value File, Global Days column
					 (labeled "Glob Days"), provides the postoperative periods that apply to each
					 surgical procedure. The payment rules for surgical procedures apply to codes
					 with entries of 000, 010, 090. For workers' compensation, the global period
					 will not apply to codes with "YYY".
(A) Codes
					 with "000" in the Global Days column are minor procedures or endoscopies with
					 related preoperative and postoperative relative values on the day of the
					 procedure only included in the fee schedule payment amount; evaluation and
					 management services on the day of the procedure are generally not
					 payable.
(B) Codes with "010" in
					 the Global Days column are minor procedures or endoscopies with preoperative
					 relative values on the day of the procedure and postoperative relative values
					 during a 10 day postoperative period included in the fee schedule amount;
					 evaluation and management services on the day of the procedure and during the
					 10-day postoperative period generally not payable.
(C) Codes with "090" in the Global Days
					 column are major surgeries with a 1-day preoperative period and 90-day
					 postoperative period included in the fee schedule amount.
(D) Codes with "ZZZ" are surgical codes
					 related to another service and are always included in the global period of the
					 other service. They are add-on codes that are always billed with another
					 service. There is no postoperative work included in the fee schedule payment
					 for the "ZZZ" codes. Payment is made for both the primary and the add-on codes,
					 and the global period assigned is applied to the primary
					 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 9789.16.3 - Surgery - Global Fee - Miscellaneous Rules

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Relationship to Correct Coding Initiative
					 (CCI)
The CCI edits allow the claims administrator to detect
						instances of fragmented billing for certain intra-operative services and other
						services furnished on the same day as the surgery that are considered to be
						components of the surgical procedure and, therefore, included in the global
						surgical fee. When both correct coding and global surgery edits apply to the
						same claim, the claims administrator shall first apply the correct coding
						edits, then, apply the global surgery edits to the correctly coded
						services.
(b) Claims From
					 Physicians Who Furnish Less Than the Global Package (Split Global Care)
(1) For surgeries that are billed with either
					 modifier "-54" or "-55," the claims administrator shall pay the applicable
					 percentage of the fee schedule payment. Columns labeled "Pre Op", "Intra Op"
					 and "Post Op" of the National Physician Fee Schedule Relative Value File, list
					 the percentages for pre-, intra-, and postoperative care of the total RVUs for
					 major surgical procedures and for minor surgeries with a postoperative period
					 of 10 days. The intra-operative percentage includes postoperative hospital
					 visits.
(2) Where more than one
					 physician bills for the postoperative care, the claims administrator will
					 apportion the postoperative percentage according to the number of days each
					 physician was responsible for the patient's care by dividing the postoperative
					 allowed amount by the number of post-op days and that amount is multiplied by
					 the number of days each physician saw the patient.
EXAMPLE
Dr. Jones bills for procedure "42145-54" performed on
						March 1 and states that he cared for the patient through April 29. Dr. Smith
						bills for procedure "42145-55" and states that she assumed care of the patient
						on April 30. The percentage of the total fee amount for the postoperative care
						for this procedure is determined to be 17 percent and the length of the global
						period is 90 days. Since Dr. Jones provided postoperative care for the first 60
						days, he will receive 66 
						2/3 percent
						of the total fee of 17 percent since 60/90 = .6666. Dr. Smith's 30 days of
						service entitle her to 30/90 or .3333 of the fee.
6666 x .17 = .11333 or 11.3%; and
3338 x .17 = .057 or 5.7%.
Thus, Dr. Jones will be paid at a rate of 11.3 percent
						(66.7 percent of 17 percent). Dr. Smith will be paid at a rate of 5.7 percent
						(33.3 percent of 17 percent).
(3) Procedures with a "000" entry in "Glob
					 Days" column have an entry of "0.0000" in the Pre Op, Intra Op and Post Op
					 columns. Split global care does not apply to these
					 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 9789.16.4 - Surgery - Global Fee; Exception: Circumstances Allowing E and M Code During the Global Period; Primary Treating Physician's Progress Report (PR-2)

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Notwithstanding
					 sections 9789.16.2 -
					 9789.16.3, where a surgical code is
					 subject to a global period, the provider may separately bill an E&M service
					 during the global period in the following circumstance.
The provider may bill one or more evaluation and
						management codes for medically necessary services that exceed the number of
						visits that are listed for the global surgical code in the Medicare Physician
						Fee Schedule's "Physician Time File". See section
						9789.19 for the Physician Time
						File, by date of service.
Calculation shall be made as follows: For the surgical
						procedure subject to the global days, add the number of visits for all E&M
						services shown on that row in the Physician Time File. Round up if the total
						number of visits includes a half visit. If the physician provides E&M
						services in excess of the total number of E&M visits shown for the surgical
						code, medically necessary E&M services in excess of that number may be
						separately billed.
(b) The
					 Primary Treating Physician's Progress reports (PR-2 or the equivalent allowed
					 by section 9785) are separately reimbursable
					 even if the change in the patient's condition or treatment warranting a
					 progress report occurs during the surgical global follow-up period.
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 9789.16.6 - Surgery - Bilateral Surgeries

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Bilateral surgeries are procedures
					 performed on both sides of the body during the same operative session or on the
					 same day.
The terminology for some procedure codes includes the
						terms "bilateral" (e.g., code 27395; Lengthening of the hamstring tendon;
						multiple, bilateral) or "unilateral or bilateral" (e.g., code 52290;
						cystourethroscopy; with ureteral meatotomy, unilateral or bilateral). The
						payment adjustment rules for bilateral surgeries do not apply to procedures
						identified by CPT as "bilateral" or "unilateral or bilateral" since the fee
						schedule reflects any additional work required for bilateral surgeries. The
						Bilateral Surgery ("Bilat Surg") column of the National Physician Fee Schedule
						Relative Value File indicates whether the bilateral payment adjustment rules
						apply to a surgical procedure.
(b) Billing Instructions for Bilateral
					 Surgeries
(1) If a procedure is not identified
					 by its terminology as a bilateral procedure (or unilateral or bilateral),
					 report the procedure with modifier "-50." (NOTE: This differs from the CPT
					 coding guidelines which indicate that bilateral procedures should be billed as
					 two line items.)
If a procedure is identified by the terminology as
						bilateral (or unilateral or bilateral), as in codes 27395 and 52290, do not
						report the procedure with modifier "-50".
(A) If the Bilateral Surgery column of the
					 National Physician Fee Schedule Relative Value File contains an indicator of
					 "0," "2," or "3," the payment adjustment rules for bilateral surgeries do not
					 apply. Payment is determined by the lower of the billed amount or 100 percent
					 of the fee schedule amount unless other payment adjustment rules apply.
NOTE: Some codes which have a bilateral indicator of "0"
						in the Bilateral Surgery column may be performed more than once on a given day.
						These are services that would never be considered bilateral and thus should not
						be billed with modifier "-50." Where such a code is billed on multiple line
						items or with more than 1 in the units field and the claims administrator has
						determined that the code may be reported more than once, bypass the "0"
						bilateral indicator and refer to the multiple surgery field for
						pricing.
(B) If Bilateral
					 Surgery column of the National Physician Fee Schedule Relative Value File
					 contains an indicator of "1," the standard payment adjustment for bilateral
					 procedures apply. Payment is determined by the lower of the billed amount or
					 150 percent of the fee schedule amount. (Multiply the payment amount for the
					 surgery by 150 percent.)
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 9789.16.8 - Surgery - Assistants-at-Surgery

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For assistant-at-surgery services performed by
						physicians, the fee schedule amount equals 16 percent of the amount otherwise
						applicable for the surgical payment.
Procedures billed with the assistant-at-surgery physician
						modifiers -80, -81, -82, or the AS modifier for physician assistants, nurse
						practitioners and clinical nurse specialists, are subject to the
						assistant-at-surgery policy.
If the Assistant at Surgery ("Asst Surg") column of the
						National Physician Fee Schedule Relative Value File contains an indicator of
						"0" the physician or non-physician practitioner must submit documentation to
						establish medical necessity for use of an assistant at surgery. If the
						Assistant at Surgery column contains an indicator of "1", assistant-at-surgery
						is not payable. If the Assistant at Surgery column contains indicator "2", the
						assistant at surgery may be paid.
Payment is not generally allowed for an assistant surgeon
						when payment for either two surgeons (modifier "-62") or team surgeons
						(modifier "-66") is appropriate.
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 9789.17.1 - Radiology Diagnostic Imaging Multiple Procedures

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Specified diagnostic imaging procedures
					 are designated in the "Diagnostic Imaging Service Subject to the Multiple
					 Procedure Payment Reduction (MPPR)" file of the CMS Physician Fee Schedule
					 final rule, and in the CMS National Physician Fee Schedule Relative Value excel
					 file, to indicate that the Multiple Procedure Payment Reduction (MPPR) shall be
					 applied to the professional component (PC) and technical component (TC) of the
					 procedure, when multiple services are furnished to the same patient, in the
					 same session, on the same day, by one or more physicians in the same group
					 practice. The MPPR shall apply to both PC-only services, TC-only services, and
					 to the PC and TC of global services. If the procedure is reported in the same
					 session, on the same day, and furnished to the same patient, by one or more
					 physicians in the same group practice (same Group National Provider Identifier
					 (NPI)), the maximum reimbursement shall be determined as follows:
(1) Full payment is made for each PC and TC
					 with the highest payment under the physician fee schedule.
(2)
(A) For
					 services rendered prior to March 1, 2017 payment is made at 75 percent for
					 subsequent PC services furnished to the same patient, in the same session, on
					 the same day, by one or more physicians in the same group practice
					 (NPI).
(B) For services rendered on
					 or after March 1, 2017, payment is made at 95 percent for subsequent PC
					 services furnished to the same patient, in the same session, on the same day,
					 by one or more physicians in the same group practice (NPI).
(3) Payment is made at 50 percent for
					 subsequent TC services furnished to the same patient, in the same session, on
					 the same day, by one or more physicians in the same group practice
					 (NPI).
(4) The individual PC and TC
					 services with the highest payments under the physician fee schedule of globally
					 billed services must be determined in order to calculate the
					 MPPR.