Bulletin 94-2

May 5, 1994

CLARIFICATION OF ISSUES CONCERNING THE

OFFICIAL MEDICAL FEE SCHEDULE

This is the second in a series of Newslines designed to address issues raised in the new rules and regulations. This issue will address four commonly-asked questions we have received concerning the Official Medical Fee Schedule.

Q. Are services provided by free standing surgery centers covered by the Fee Schedule?

A. Any services which are included in the current fee schedule would apply to these facilities, as they do to any other facility. The Fee Schedule applies to all covered medical services provided, referred or prescribed by physicians, regardless of the type of facility in which the medical services are performed.

The Fee Schedule also provides that health facilities which are licensed under (a), (b), or (f) of Section 1250 of the Health and Safety Code may charge a "facility fee" for the use of the emergency room or operating room of the facility. However, the schedule is silent on facility fees for free standing surgery centers or other facilities which are not licensed under this section. At the June hearings we will be proposing language to make it explicit that other appropriately licensed surgery centers can also charge a facility fee. In regulatory hearings to be scheduled this fall we will be addressing the reimbursement level for emergency room or operating room facility fees.

Q. Are supplies such as surgical trays included in the reimbursement of procedures under the fee schedule?

A. Not necessarily. The Fee Schedule provides, at page two, under the section on Supplies and Materials , that reimbursement for supplies and materials (e.g. sterile trays) which the physician provides over and above supplies and materials usually included with the service rendered may be charged for separately "By Report" (BR). Procedure code 99070 should be used to bill under this section. The trays, supplies or materials provided should be identified in the bill. We intend to address this issue more comprehensively in the pharmaceutical and supply fee schedule, which will be presented in the fall hearings.

Bulletin 94-2

Page 2

Q. Which schedule should be used to reimburse medical testimony: the Official Medical Fee Schedule or the Medical-Legal Fee Schedule?

A. The Medical-legal Fee Schedule should be used in virtually all cases. This schedule [which begins at Title 8, CCR [[section]]9793] defines "medical-legal testimony" as "expert testimony provided by a physician at a deposition or workers' compensation appeals board hearing, regarding the medical opinion submitted by the physician." This section would therefore apply, in almost every case, to the testimony of treating physicians as well as to the testimony of evaluating physicians. Reimbursement of medical testimony is provided under Procedure Code ML 104 at $50.00 per quarter hour of testimony, with a one hour minimum. Reasonable preparation and travel time is also included.

The Official Medical Fee Schedule currently includes medical testimony under procedure code 99075. This code will be amended in the June hearings to incorporate the reimbursement language contained in the medical legal fee schedule.

Q. When can a physician be reimbursed for a follow-up Evaluation and Management service under the physical medicine section of the Fee Schedule?

A. As noted on page 263 of the Fee Schedule, a physician may be reimbursed for follow-up Evaluation and Management (E/M) services only when: (1) there is a definite change in the patient's condition; (2) the patient fails to respond to treatment; (3) the patient's condition becomes permanent and stationary, or the patient is ready for discharge; (4) it is medically necessary to provide evaluation services over and above those normally provided during the therapeutic services; or (5) it is medically necessary to evaluate the patient's response to the care rendered.

When follow-up treatment is provided and none of these conditions apply, a separate E/M service would not be reimbursed. As provided under Subsection 1(e) on page 264, the value of an office visit is already included in the reimbursement of the physical medicine treatment codes. When a separate E/M service is warranted and treatment is provided on the same visit, the physician should subtract 2.4 units of value from the total. The 2.4 units represents the value of the office visit, which is also included in the E/M service.

The issue of when it is appropriate for a provider to bill an E/M code has been the subject of much controversy. It is apparent that this issue needs clarification, and it will be addressed at our June hearings.

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