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

§9789.11. Physician Services Rendered on or After July 1, 2004, but Before January 1, 2014.

(a) Except as specified below, or otherwise provided in this Article, the ground rule materials set forth in each individual section of the OMFS 2003 are applicable to physician services rendered on or after July 1, 2004, but before January 1, 2014.

(1) The OMFS 2003's “General Information and Instructions” section is not applicable. The “General Information and Instructions, Effective for Dates of Service on or after July 1, 2004,” are incorporated by reference and will be made available on the Division of Workers' Compensation Internet site http://www.dir.ca.gov/DWC/OMFS9904.htm or upon request to the Administrative Director at:

DIVISION OF WORKERS' COMPENSATION (ATTENTION: OMFS - PHYSICIAN SERVICES)

P.O. BOX 420603

SAN FRANCISCO, CA 94142

(b) Except as specified in this section, or otherwise provided in this Article, for physician services rendered on or after July 1, 2004, but before January 1, 2014, the maximum allowable reimbursement amount set forth in the OMFS 2003 for each procedure code is reduced by five (5) percent, except that those procedures that are reimbursed under OMFS 2003 at a rate between 100% and 105% of the Medicare rate will be reduced between zero and 5% so that the OMFS reimbursement will not fall below the Medicare rate. The reduction rate for each procedure is set forth as the adjustment factor in Table A. Reimbursement for procedures that are reimbursed under OMFS 2003 at a rate below the Medicare rate will not be reduced.

(c)(1) Table A, “OMFS Physician Services Fees for Services Rendered on or after July 1, 2004,” which sets forth each individual procedure code with its corresponding relative value, conversion factor, percentage reduction calculation (between 0 and 5.0%), and maximum reimbursable fee, is incorporated by reference.

(2) Table A, “OMFS Physician Services Fees for Services Rendered on or after January 14, 2005,” which sets forth each individual procedure code with its corresponding relative value, conversion factor, percentage reduction calculation (between 0 and 5.0%), and maximum reimbursable fee, is incorporated by reference.

(3) Table A, “OMFS Physician Services Fees for Services Rendered on or after May 14, 2005,” which sets forth each individual procedure code with its corresponding relative value, conversion factor, percentage reduction calculation (between 0 and 5.0%), and maximum reimbursable fee, is incorporated by reference.

(4) Table A and its addenda may be obtained from the Division of Workers' Compensation Internet site http://www.dir.ca.gov/DWC/OMFS9904.htm or upon request to the Administrative Director at:

DIVISION OF WORKERS' COMPENSATION (ATTENTION: OMFS - PHYSICIAN SERVICES)

P.O. BOX 420603

SAN FRANCISCO, CA 94142

(d)(1) Except as specified in this section, or otherwise provided in this Article, except for anesthesia services, to determine the maximum allowable reimbursement for a physician service rendered on or after July 1, 2004, but before January 1, 2014, the following formula is utilized: RVU x conversion factor y percentage reduction calculation = maximum reasonable fee before application of ground rules. Applicable ground rules set forth in the OMFS 2003 and the “General Information and Instructions, Effective for Dates of Service on or after July 1, 2004,” are then applied to calculate the maximum reasonable fee.

(2) Except as specified in this section, or otherwise provided in this Article, to determine the maximum allowable reimbursement for anesthesia services (CPT Codes 00100 through 01999) rendered after January 1, 2004, but before January 1, 2014, the following formula is utilized: (basic value + modifying units (if any) + time value) y (conversion factor x .95) = maximum reasonable fee.

(e) Except as specified in this section, or otherwise provided in this Article, the following procedures in the Pathology and Laboratory section (both professional and technical component), rendered after January 1, 2004, but before January 1, 2014, will be reimbursed under this section: CPT Codes 80500, 80502; 85060 through 85102; 86077 through 86079; 87164; and 88000 through 88399. All other pathology and laboratory services will be reimbursed pursuant to Section 9789.50, including but not limited to: CPT Codes 80002 through 80440; 81000 through 85048; 85130 through 86063; 86140 through 87163; 87166 through 87999; and 89050 through 89399.

(f) Except as specified in this section, or otherwise provided in this Article, for physician services rendered on or after February 15, 2007, but before January 1, 2014, the maximum allowable reimbursement amounts for procedure codes 99201 through 99205 and 99211 through 99215 are set forth in the February, 2007 Addendum to Table A, “OMFS Physician Services Fees for Services Rendered on or after February 15, 2007.” The February, 2007 Addendum to Table A, “OMFS Physician Services Fees for Services Rendered on or after February 15, 2007”, which sets forth individual procedure codes with the corresponding maximum reimbursable fees, is incorporated by reference.

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 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 section heading and section, transmitted to OAL 4-30-2004 and filed 6-15-2004 (Register 2004, No. 25).

3. Amendment of subsection (a)(1), redesignation and amendment of former subsection (c) as new subsections (c)(1) and (c)(3), new subsection (c)(2) and adoption of new revision of Table A (incorporated by reference) filed 12-15-2004 as an emergency; operative 1-14-2005 (Register 2004, No. 51). A Certificate of Compliance must be transmitted to OAL by 5-16-2005 or emergency language will be repealed by operation of law on the following day.

4. Readoption of 12-15-2004 order, with additional amendments, filed 5-12-2005 as an emergency; operative 5-14-2005 (Register 2005, No. 19). A Certificate of Compliance must be transmitted to OAL by 9-12-2005 or emergency language will be repealed by operation of law on the following day.

5. Certificate of Compliance as to 5-12-2005 order transmitted to OAL 8-22-2005 and filed 9-29-2005 (Register 2005, No. 39).

6. Amendment of subsection (c)(4) and new subsection (f) submitted to the Office of Administrative Law for printing only as exempt from the Administrative Procedure Act and review by the Office of Administrative Law pursuant to section 11340.9(g) of the Government Code (Register 2007, No. 7).

7. Editorial correction of History 6 (Register 2013, No. 39).

8. Amendment of section heading and section filed 2-4-2015; operative 3-5-2015. Submitted to OAL for printing only pursuant to Government Code section 11340.9 (Register 2015, No. 6).