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

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Except for fees determined pursuant to §
											9789.18.1 et seq., (Anesthesia),
						the base maximum reasonable fee for physician and non-physician professional
						medical practitioner services shall be the non-facility or facility fee
						calculated as follows:
(a)
					 Non-facility site of service fee calculation:
For dates of service on or after January 1, 2014, but
						before January 1, 2019:
[(Work RVU * Statewide Work GAF) +
(Non-Facility PE RVU * Statewide PE GAF) +
(MP RVU * Statewide MP GAF)] * Conversion Factor (CF) =
						Base Maximum Fee
Key:
RVU = Relative Value Unit
GAF = Average Statewide Geographic Adjustment
								Factor
Work = Physician Work
PE = Practice Expense
MP = Malpractice Expense
For dates of service on or after January 1, 2019:
[(Work RVU * Work GPCI) +
(Non-Facility PE RVU * PE GPCI) +
(MP RVU * MP GPCI)] * Conversion Factor (CF) = Base
						Maximum Fee
Key:
RVU = Relative Value Unit
GPCI = Geographic Practice Cost Index (by locality
								corresponding to the county where service was provided)
Work = Physician Work
PE = Practice Expense
MP = Malpractice Expense
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.
(b) Facility site of service fee calculation:
For dates of service on or after January 1, 2014, but
						before January 1, 2019:
[(Work RVU * Statewide Work GAF) +
(Facility PE RVU * Statewide PE GAF) +
(MP RVU * Statewide MP GAF)] * Conversion Factor = Base
						Maximum Fee
Key:
RVU = Relative Value Unit
GAF = Average Statewide Geographic Adjustment
								Factor
Work = Physician Work
PE = Practice Expense
MP = Malpractice Expense
For dates of service on or after January 1, 2019:
[(Work RVU * Work GPCI) +
(Facility PE RVU * PE GPCI) +
(MP RVU * MP GPCI)] * Conversion Factor (CF) = Base
						Maximum Fee
Key:
RVU = Relative Value Unit
GPCI = Geographic Practice Cost Index (by locality
								corresponding to the county where service was provided)
Work = Physician Work
PE = Practice Expense
MP = Malpractice Expense
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.
(c) "Facility RVUs" shall be used where the
					 place of service is listed as facility ("F") in subdivision (d). "Non-Facility
					 Total RVUs" shall be used where the place of service is listed as nonfacility
					 ("NF") in subdivision (d).
(d)
(1) The place of service code (POS) is used
					 to identify where the procedure is furnished. All services shall be assigned
					 the POS code for the setting in which the patient received the face-to-face
					 service. In cases where the face-to-face requirement is obviated such as those
					 when a physician/practitioner provides the PC/interpretation of a diagnostic
					 test, from a distant site, the POS code assigned by the physician/practitioner
					 shall be the setting in which the patient received the Technical Component (TC)
					 of the service.
(2) This
					 face-to-face rule does not apply where the patient is receiving care as a
					 registered inpatient or an outpatient of a hospital. The correct POS code
					 assignment will be for the setting in which the patient is receiving inpatient
					 care or outpatient care from a hospital, including the inpatient hospital (POS
					 code 21) or the outpatient hospital (POS 19 or POS 22).
POS Code and Name
Payment Rate
Description
Facility = F
Nonfacility = NF
01 Pharmacy
NF
A facility or location where drugs and other
								medically related items and services are sold, dispensed, or otherwise provided
								directly to patients.
02 Telehealth
F
The location where health services and health related
								services are provided or received, through a telecommunication system.
(Effective for services on or after March 1, 2017,
								and prior to March 1, 2020. For services on or after March 1, 2020, and prior
								to February 15, 2024, report the POS code that would have been reported had the
								service been furnished in person.)
02 Telehealth Provided Other than in Patient's
								Home
F
The location where health services and health related
								services are provided or received, through telecommunication technology.
								Patient is not located in their home when receiving health services or health
								related services through telecommunication technology.
(Effective for services rendered on or after February
								15, 2024.)
03 School
NF
A facility whose primary purpose is education.
04 Homeless Shelter
NF
A facility or location whose primary purpose is to
								provide temporary housing to homeless individuals (e.g., emergency shelters,
								individual or family shelters).
09 Prison/Correctional Facility
NF
A prison, jail, reformatory, work farm, detention
								center, or any other similar facility maintained by either Federal, State or
								local authorities for the purpose of confinement or rehabilitation of adult or
								juvenile criminal offenders.
10 Telehealth Provided in Patient's Home
NF
The location where health services and health related
								services are provided or received, through telecommunication technology.
								Patient is located in their home (which is a location other than a hospital or
								other facility where the patient receives care in a private residence) when
								receiving health services or health related services through telecommunication
								technology.
(Effective for services rendered on or after February
								15, 2024.)
11 Office
NF
Location, other than a hospital, skilled nursing
								facility (SNF), military treatment facility, community health center, State or
								local public health clinic, or intermediate care facility (ICF), where the
								health professional routinely provides health examinations, diagnosis, and
								treatment of illness or injury on an ambulatory basis.
12 Home or Private Residence of Patient
NF
Location, other than a hospital or other facility,
								where the patient receives care in a private residence.
13 Assisted Living Facility
NF
Congregate residential facility with self-contained
								living units providing assessment of each resident's needs and on-site support
								24 hours a day, 7 days a week, with the capacity to deliver or arrange for
								services including some health care and other services.
14 Group Home
NF
A residence, with shared living areas, where clients
								receive supervision and other services such as social and/or behavioral
								services, custodial service, and minimal services (e.g., medication
								administration).
15 Mobile Unit
NF
A facility/unit that moves from place-to-place
								equipped to provide preventive, screening, diagnostic, and/or treatment
								services.
16 Temporary Lodging
NF
A short-term accommodation such as a hotel, camp
								ground, hostel, cruise ship or resort where the patient receives care, and
								which is not identified by any other POS code.
17 Walk-in Retail Health Clinic
NF
A walk-in health clinic, other than an office, urgent
								care facility, pharmacy or independent clinic and not described by any other
								Place of Service code, that is located within a retail operation and provides,
								on an ambulatory basis, preventive and primary care services.
18 Place of Employment/Worksite
NF
A location, not described by any other POS code,
								owned or operated by a public or private entity where the patient is employed,
								and where a health professional provides on-going or episodic occupational
								medical, therapeutic or rehabilitative services to the individual.
19 Off Campus-Outpatient Hospital
F
A portion of an off-campus hospital provider based
								department which provides diagnostic, therapeutic (both surgical and
								nonsurgical), and rehabilitation services to sick or injured persons who do not
								require hospitalization or institutionalization.
(Effective for Services on or after January 1,
								2016)
20 Urgent Care Facility
NF
Location, distinct from a hospital emergency room, an
								office, or a clinic, whose purpose is to diagnose and treat illness or injury
								for unscheduled, ambulatory patients seeking immediate medical attention.
21 Inpatient Hospital
F
A facility, other than psychiatric, which primarily
								provides diagnostic, therapeutic (both surgical and nonsurgical), and
								rehabilitation services by, or under, the supervision of physicians to patients
								admitted for a variety of medical conditions.
22 Outpatient Hospital
F
A portion of a hospital which provides diagnostic,
								therapeutic (both surgical and nonsurgical), and rehabilitation services to
								sick or injured persons who do not require hospitalization or
								institutionalization.
(Effective for Services prior to January 1,
								2016)
22 On Campus-Outpatient Hospital
F
A portion of a hospital's main campus which provides
								diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation
								services to sick or injured persons who do not require hospitalization or
								institutionalization.
(Effective for Services on or after January 1,
								2016)
23 Emergency Room-Hospital
F
A portion of a hospital where emergency diagnosis and
								treatment of illness or injury is provided.
24 Ambulatory Surgical Center
F
A freestanding facility, other than a physician's
								office, where surgical and diagnostic services are provided on an ambulatory
								basis.
31 Skilled Nursing Facility
F
A facility which primarily provides inpatient skilled
								nursing care and related services to patients who require medical, nursing, or
								rehabilitative services but does not provide the level of care or treatment
								available in a hospital.
32 Nursing Facility
NF
A facility which primarily provides to residents
								skilled nursing care and related services for the rehabilitation of injured,
								disabled, or sick persons, or, on a regular basis, health-related care services
								above the level of custodial care to other than mentally retarded
								individuals.
33 Custodial Care Facility
NF
A facility which provides room, board and other
								personal assistance services, generally on a longterm basis, and which does not
								include a medical component.
34 Hospice -- for inpatient care
F
A facility, other than a patient's home, in which
								palliative and supportive care for terminally ill patients and their families
								are provided.
41 Ambulance -- Land
F
A land vehicle specifically designed, equipped and
								staffed for lifesaving and transporting the sick or injured.
42 Ambulance -- Air or Water
F
An air or water vehicle specifically designed,
								equipped and staffed for lifesaving and transporting the sick or injured.
49 Independent Clinic
NF
A location, not part of a hospital and not described
								by any other Place of Service code, that is organized and operated to provide
								preventive, diagnostic, therapeutic, rehabilitative, or palliative services to
								outpatients only.
51 Inpatient Psychiatric Facility
F
A facility that provides inpatient psychiatric
								services for the diagnosis and treatment of mental illness on a 24-hour basis,
								by or under the supervision of a physician.
52 Psychiatric Facility-Partial Hospitalization
F
A facility for the diagnosis and treatment of mental
								illness that provides a planned therapeutic program for patients who do not
								require full time hospitalization, but who need broader programs than are
								possible from outpatient visits to a hospital-based or hospital-affiliated
								facility.
53 Community Mental Health Center
F
A facility that provides the following services:
								outpatient services, including specialized outpatient services for children,
								the elderly, individuals who are chronically ill, and residents of the CMHC's
								mental health services area who have been discharged from inpatient treatment
								at a mental health facility; 24 hour a day emergency care services; day
								treatment, other partial hospitalization services, or psychosocial
								rehabilitation services; screening for patients being considered for admission
								to State mental health facilities to determine the appropriateness of such
								admission; and consultation and education services.
54 Intermediate Care Facility/Mentally Retarded
NF
A facility which primarily provides health-related
								care and services above the level of custodial care to mentally retarded
								individuals but does not provide the level of care or treatment available in a
								hospital or skilled nursing facility (SNF).
55 Residential Substance Abuse Treatment
								Facility
NF
A facility which provides treatment for substance
								(alcohol and drug) abuse to live-in residents who do not require acute medical
								care. Services include individual and group therapy and counseling, family
								counseling, laboratory tests, drugs and supplies, psychological testing, and
								room and board.
56 Psychiatric Residential Treatment Center
F
A facility or distinct part of a facility for
								psychiatric care which provides a total 24-hour therapeutically planned and
								professionally staffed group living and learning environment.
57 Non-residential Substance Abuse Treatment
								Facility
NF
A location which provides treatment for substance
								(alcohol and drug) abuse on an ambulatory basis. Services include individual
								and group therapy and counseling, family counseling, laboratory tests, drugs
								and supplies, and psychological testing.
60 Mass Immunization Center
NF
A location where providers administer pneumococcal
								pneumonia and influenza virus vaccinations and submit these services as
								electronic media claims, paper claims, or using the roster billing method. This
								generally takes place in a mass immunization setting, such as, a public health
								center, pharmacy, or mall but may include a physician office setting.
61 Comprehensive Inpatient Rehabilitation
								Facility
F
A facility that provides comprehensive rehabilitation
								services under the supervision of a physician to inpatients with physical
								disabilities. Services include physical therapy, occupational therapy, speech
								pathology, social or psychological services, and orthotics and prosthetics
								services.
62 Comprehensive Outpatient Rehabilitation
								Facility
NF
A facility that provides comprehensive rehabilitation
								services under the supervision of a physician to outpatients with physical
								disabilities. Services include physical therapy, occupational therapy, and
								speech pathology services.
65 End-Stage Renal Disease Treatment Facility
NF
A facility other than a hospital, which provides
								dialysis treatment, maintenance, and/or training to patients or caregivers on
								an ambulatory or home-care basis.
71 State or Local Public Health Clinic
NF
A facility maintained by either State or local health
								departments that provides ambulatory primary medical care under the general
								direction of a physician.
72 Rural Health Clinic
NF
A certified facility which is located in a rural
								medically underserved area that provides ambulatory primary medical care under
								the general direction of a physician.
81 Independent Laboratory
NF
A laboratory certified to perform diagnostic and/or
								clinical tests independent of an institution or a physician's office.
99 Other Place of Service
NF
Other place of service not identified above.