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 9789.33 - Hospital Outpatient Departments and Ambulatory Surgical Centers Fee Schedule - Determination of Maximum Reasonable Fee

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) In accordance with section
					 9789.32, the maximum allowable
					 payment for hospital outpatient department or ambulatory surgical center
					 facility fees for services provided on an outpatient basis and payable under
					 the Medicare (CMS) HOPPS, shall be determined based on the following. In
					 accordance with Section
					 9789.30(ab), an
					 extra percentage reimbursement shall be used in lieu of an additional payment
					 for high cost outlier cases.
Standard payment.
Date of Service
Status Code
								Indicators
Hospital Outpatient Department Services that are: Surgical
								procedures; Emergency Room Visits; or services that are an integral part of the
								surgical procedure or emergency room visit
Ambulatory Surgical Centers
								surgical procedures
Hospital Outpatient Department Services (as defined
								in Section 9789.30(q)) that
								are Facility Only Services (as defined in Section
								9789.30(k))
Hospital
								Outpatient Department Services (as defined in Section
								9789.30(q)) that
								are Other Services (as defined in Section
								9789.30(u))
For services rendered before March 1,
								2008
"S", "T", "X", or "V"
APC relative weight x adjusted
								conversion factor x 1.22 workers' compensation multiplier, pursuant to Section
								9789.30(ab). See
								Section 9789.39(b) for the
								APC relative weight by date of service.
APC relative weight x adjusted
								conversion factor x 1.22 workers' compensation multiplier, pursuant to Section
								9789.30(ab). See
								Section 9789.39(b) for the
								APC relative weight by date of service.
Not applicable. Payable under
								Sections 9789.10 and
								9789.11.
Not applicable.
								Payable under Sections
								9789.10 and
								9789.11.
For services rendered on or after March 1, 2008 but
								before March 1, 2009
"S", "T", "X", or "V", or "Q". Status code
								indicator "Q" must qualify for separate payment.
APC relative weight x
								adjusted conversion factor x 1.22 workers' compensation multiplier, pursuant to
								Section 9789.30(ab). See
								Section 9789.39(b) for the
								APC relative weight by date of service.
APC relative weight x adjusted
								conversion factor x 1.22 workers' compensation multiplier, pursuant to Section
								9789.30(ab). See
								Section 9789.39(b) for the
								APC relative weight by date of service.
Not applicable. Payable under
								Sections 9789.10 and
								9789.11.
Not applicable.
								Payable under Sections
								9789.10 and
								9789.11.
For services rendered on or after March 1, 2009 but
								before January 1, 2013
"S", "T", "X", or "V", "Q1", Q2", or "Q3".
								Status code indicators "Q1", "Q2", and "Q3" must qualify for separate
								payment.
APC relative weight x adjusted conversion factor x 1.22
								workers' compensation multiplier, pursuant to Section
								9789.30(ab). See
								Section 9789.39(b) for the
								APC relative weight by date of service.
APC relative weight x adjusted
								conversion factor x 1.22 workers' compensation multiplier, pursuant to Section
								9789.30(ab). See
								Section 9789.39(b) for the
								APC relative weight by date of service.
Not applicable. Payable under
								Sections 9789.10 and
								9789.11.
Not applicable.
								Payable under Sections
								9789.10 and
								9789.11.
For services rendered on or after January 1, 2013
								but before September 1, 2014
"S", "T", "X", or "V","Q1", Q2", or "Q3".
								Status code indicators "Q1", "Q2", and "Q3" must qualify for separate
								payment.
APC relative weight x adjusted conversion factor x 1.22
								workers' compensation multiplier, pursuant to Section
								9789.30(ab). See
								Section 9789.39(b) for the
								APC relative weight by date of service.
APC relative weight x adjusted
								conversion factor x 0.82 workers' compensation multiplier, pursuant to Section
								9789.30(ab). See
								Section 9789.39(b) for the
								APC relative weight by date of service.
Not applicable. Payable under
								Sections 9789.10 and
								9789.11.
Not applicable.
								Payable under Sections
								9789.10 and
								9789.11
For services rendered on or after September 1, 2014
								but before December 15, 2016
"S", "T", "X", or "V","Q1", Q2", or "Q3".
								Status code indicators "Q1", "Q2", and "Q3" must qualify for separate
								payment.
APC relative weight x adjusted conversion factor x 1.212
								workers' compensation multiplier, pursuant to Section
								9789.30(ab). See
								Section 9789.39(b) for the
								APC relative weight by date of service.
APC relative weight x adjusted
								conversion factor x 0.8081 workers' compensation multiplier, pursuant to
								Section 9789.30(ab). See
								Section 9789.39(b) for the
								APC relative weight by date of service.
APC relative weight x adjusted
								conversion factor x 1.0101 workers' compensation multiplier, pursuant to
								Section 9789.30(ab). See
								Section 9789.39(b) for the
								APC relative weight by date of service
Payable under Section
								9789.32(c)
For services rendered on or after December 15,
								2016
"S," "T," "V," "Q1," Q2," "Q3," "J1," or "J2." Status code
								indicators must qualify for separate payment.
APC relative weight x
								adjusted conversion factor x 1.178 workers' compensation multiplier, pursuant
								to Section 9789.30(ab). See
								Section 9789.39(b) for the
								APC relative weight by date of service.
APC relative weight x adjusted
								conversion factor x 0.8081 workers' compensation multiplier, pursuant to
								Section 9789.30(ab). See
								Section 9789.39(b) for the
								APC relative weight by date of service.
Not applicable. These services
								are payable as "Other Services".
APC relative weight x adjusted
								conversion factor x 1.0101 workers' compensation multiplier, pursuant to
								Section 9789.30(ab). See
								Section 9789.39(b) for the
								APC relative weight by date of service.
Table A in Section
						9789.34 contains an "adjusted
						conversion factor" which incorporates the standard conversion factor, wage
						index and inflation factor. The maximum payment rate for ASCs and non-listed
						hospitals can be determined according to Table A and subdivision (a).
For services rendered before February 15, 2006, Table B
						in Section 9789.35 contains an "adjusted
						conversion factor" which incorporates the standard conversion factor, wage
						index and inflation factor.
For services rendered on or after February 15, 2006,
						table B in Section
						9789.35 contains an "adjusted
						conversion factor" which incorporates the standard conversion factor, wage
						index, rural SCH adjustment factor, and inflation factor, as described in CMS'
						2006 Hospital Outpatient Prospective Payment System final rule of November 10,
						2005, published in the Federal Register (CMS-1501-FC, 70 FR 68516), at page
						68556.
The maximum payment rate for the listed hospital
						outpatient departments can be determined according to Table B and subdivision
						(a).
(1) Procedure codes for drugs and
					 biologicals with status code indicator "G":
APC payment rate x workers' compensation multiplier
						pursuant to Section
						9789.30(ab), by
						date of service.
(2)
					 Procedure codes for devices with status code indicator "H":
Documented paid cost, plus an additional 10% of the
						hospital outpatient department's or ASC's documented paid cost, net of
						immediate and anticipated price adjustments based upon the hospital outpatient
						department's or ASC's prior calendar year's usage for comparable devices, not
						to exceed a maximum of $ 250.00, plus any sales tax and/or shipping and
						handling charges actually paid.
(3) Procedure codes for drugs and biologicals
					 with status code indicator "K," unless rendered on or after December 15, 2016,
					 and packaged into a procedure with a status code indicator "J1" or "J2," in
					 which case no additional fee is allowable:
APC payment rate x workers' compensation multiplier
						pursuant to Section
						9789.30(ab), by
						date of service.
(4) For
					 services rendered on or after March 1, 2009: Procedure codes for blood and
					 blood products with status code indicator "R," unless rendered on or after
					 December 15, 2016, and packaged into a procedure with a status code indicator
					 "J1" or "J2," in which case no additional fee is allowable:
APC relative weight x adjusted conversion factor x
						workers' compensation multiplier pursuant to Section
						9789.30(ab), by
						date of service. See section
						9789.39(b) for APC
						relative weight by date of service.
(5) For services rendered on or after March
					 1, 2009: Procedure codes for brachytherapy services with status code indicator
					 "U":
Documented paid cost, plus an additional 10% of the
						hospital outpatient department's or ASC's documented paid cost, net of
						immediate and anticipated price adjustments based upon the hospital outpatient
						department's or ASC's prior calendar year's usage for comparable devices, not
						to exceed a maximum of $ 250.00, plus any sales tax and/or shipping and
						handling charges actually paid.
For services rendered on or after April 15, 2010:
						Procedure codes for brachytherapy services with status code indicator
						"U":
APC relative weight x adjusted conversion factor x
						workers' compensation multiplier pursuant to Section
						9789.30(ab), by
						date of service. See section
						9789.39(b) for APC
						relative weight by date of service.