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Chapter 4.5. Division of Workers' Compensation
SUBCHAPTER 1. ADMINISTRATIVE DIRECTOR -ADMINISTRATIVE RULES
Article 5.3. Official Medical Fee Schedule -- Services Rendered after January 1, 2004

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§9789.10. Physician Services - Definitions.

(a) “Basic value” means the unit value for an anesthesia procedure that is set forth in the Official Medical Fee Schedule 2003.

(b) “CMS” means the Centers for Medicare & Medicaid Services of the United States Department of Health and Human Services.

(c) “Conversion factor” or “CF” means the factor set forth below for the applicable OMFS section:

Evaluation and Management $8.50
Medicine $6.15
Surgery

$153.00

Radiology

$12.50

Pathology

$1.50

Anesthesia

$34.50

(d) “CPTÒ” means the procedure codes set forth in the American Medical Association's Physicians' Current Procedural Terminology (CPT) 1997, copyright 1996, American Medical Association, or the Physicians' Current Procedural Terminology (CPT) 1994, copyright 1993, American Medical Association.

(e) “Medicare rate” means the physician fee schedule rate derived from the Resource Based Relative Value Scale and related data, adopted for the Calendar Year 2004, published in the Federal Register on January 7, 2004, Volume 69, No. 4, pages 1117 through 1242 (CMS-1372-IFC), as amended by CMS Manual System, Pub. 100-04 Medicare Claims Processing, Transmittal 105 (February 20, 2004). The Medicare rate for each procedure is derived by the Administrative Director utilizing the non-facility rate (or facility rate if no non-facility rate exists), and a weighted average geographic adjustment factor of 1.063.

(f) “Modifying units” means the anesthesia modifiers and qualifying circumstances as set forth in the Official Medical Fee Schedule 2003.

(g) “Official Medical Fee Schedule” or “OMFS” means Article 5.3 of Subchapter 1 of Chapter 4.5 of Title 8, California Code of Regulations (Sections 9789.10 - 9789.111), adopted pursuant to Section 5307.1 of the Labor Code for all medical services, goods, and treatment provided pursuant to Labor Code Section 4600.

(h) “Official Medical Fee Schedule 2003” or “OMFS 2003” means the Official Medical Fee Schedule incorporated into Section 9791.1 in effect on December 31, 2003, which consists of the OMFS book revised April 1, 1999 and as amended for dates of service on or after July 12, 2002.

(i) “Percentage reduction calculation” means the factor set forth in Table A for each procedure code which will result in a reduction of the OMFS 2003 rate by 5%, or a lesser percent so that the reduction results in a rate that is no lower than the Medicare rate.

(j) “Physician service” means professional medical service that can be provided by a physician, as defined in Section 3209.3 of the Labor Code, and is subject to reimbursement under the Official Medical Fee Schedule. For purposes of the OMFS, “physician service” includes service rendered by a physician or by a non-physician who is acting under the supervision, instruction, referral or prescription of a physician, including but not limited to a physician assistant, nurse practitioner, clinical nurse specialist, and physical therapist.

(k) “RVU” means the relative value unit for a particular procedure that is set forth in the Official Medical Fee Schedule 2003.

(l) “Time value” means the unit of time indicating the duration of an anesthesia procedure that is set forth in the Official Medical Fee Schedule 2003.

NOTE

Authority cited: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 4603.2 and 5307.1, Labor Code.

HISTORY

1. New article 5.3 (sections 9789.10-9789.110) and 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 article heading, new introductory paragraph and amendment of subsections (d), (e) and (g), transmitted to OAL 4-30-2004 and filed 6-15-2004 (Register 2004, No. 25).

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