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Chapter 4.5. Division of Workers' Compensation
SUBCHAPTER 1. ADMINISTRATIVE DIRECTOR -ADMINISTRATIVE RULES
Article 5.3. Official Medical Fee Schedule

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§9789.12.3. Status Codes C, I, N and R.

(a) Except as otherwise provided in this fee schedule, for physician and nonphysician practitioner services billed using Current Procedural Terminology (CPT) codes, the RVUs listed in the Centers for Medicare and Medicaid Services (CMS') National Physician Fee Schedule Relative Value File will be utilized regardless of status code.

(b) When procedures with status indicator codes C, N, or R, do not have RVUs assigned under the CMS' National Physician Fee Schedule Relative Value File, these services shall be reimbursed By Report.

(c)(1) CPT codes with status indicator code I, where Medicare uses another CPT code for reporting and payment for these services shall be reimbursed according to the other CPT code used by Medicare.

(2) Healthcare Common Procedure Coding System (HCPCS) “J” procedures with status indicator I shall be reimbursed according to section 9789.13.2.

(3) CPT codes with status indicator code I, where Medicare uses HCPCS “J” code for reporting and payment for these services, shall be reimbursed according to section 9789.13.2.

(4) Maximum reasonable fee for procedures with status indicator code I, that do not meet the criteria of subdivisions (c)(1), (c)(2), or (c)(3) shall be determined as follows:

(A) use the RVUs listed in the CMS' National Physician Fee Schedule Relative Value File;

(B) If (c)(4)(A) is not applicable, use the applicable fee schedule contained in sections 9789.30-9789.70;

(C) If (c)(4)(A) or (B) are not applicable, payable By Report.

Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.

HISTORY

1. New section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and print only pursuant to Government Code section 11340.9(g) (Register 2013, No. 39).

2. Amendment filed 12-26-2013; operative 1-1-2014. Submitted to OAL as a file and print only pursuant to Government Code section 11340.9(g) (Register 2013, No. 52).

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