This information is provided free of charge by the Department of Industrial Relations from its web site at www.dir.ca.gov. These regulations are for the convenience of the user and no representation or warranty is made that the information is current or accurate. See full disclaimer at https://www.dir.ca.gov/od_pub/disclaimer.html.
 
Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director - Administrative Rules
Article 5.3. Official Medical Fee Schedule

New query

§9789.19. Update Table.

(a) Services Rendered On or After 1/1/2014. Documents listed in the following table are incorporated by reference and will be made available upon request to the Administrative Director.
Document
Services Rendered On or After 1/1/2014
Adjustment Factors
For all services other than anesthesia:
(These factors have been
2014 Total RVS adjustment factor: 1.0477
incorporated into the
2014 RVU budget neutrality factor: 1.00046
conversion factors listed
2014 RVU rescaling adjustment factor: 1.04718
below)
2014 Annual increase in the MEI: 1.008
2014 Cumulative adjustment factor: 1.0638
For anesthesia services:
2014 Total RVS adjustment factor: 1.0291
2014 RVU budget neutrality factor: 1.00046
2014 RVU rescaling adjustment factor: 1.04718
2014 anesthesia practice expense adjustment factor: 0.9823
2014 Annual increase in the MEI: 1.008
2014 Cumulative adjustment factor: 1.0449
Anesthesia Base Units
2014anesBASEfin
by CPT Code
California-Specific Codes
WC001 - Not reimbursable
WC002 - $11.91
WC003 - $38.68 for first page
$23.80 each additional page. Maximum of six pages absent mutual agreement ($157.68)
WC004 - $38.68 for first page
$23.80 each additional page. Maximum of seven pages absent mutual agreement ($181.48)
WC005 - $38.68 for first page, $23.80 each additional page. Maximum of six pages absent mutual
agreement ($157.68)
WC007 - $38.68 for first page
$23.80 each additional page. Maximum of six pages absent mutual agreement ($157.68)
WC008 - $10.26 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages.
WC009 - $10.26 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages.
WC010 - $5.13 per x-ray
WC011 - $10.26 per scan
WC012 - No Fee Prescribed/Non Reimbursable absent agreement
CCI Edits:
For services rendered on or after 1/1/2014, use:
Medically Unlikely Edits
“Practitioner Services MUE Table - Updated 10/1/2013.”
For services rendered on or after 1/23/2014, use:
“Practitioner Services MUE Table - Updated 1/1/2014.”
For services rendered on or after 4/1/2014, use:
“Practitioner Services MUE Table - Updated 4/1/2014.”
For services rendered on or after 7/1/2014, use:
“Practitioner Services MUE Table - Updated 7/1/2014.”
For services rendered on or after 10/1/2014, use:
“Practitioner Services MUE Table - Updated 10/1/2014.”
Copies of the MUE Tables are posted on the DWC website:
http://www.dir.ca.gov/dwc/OMFS9904.htm
CMS posts only the most recent version of the Practitioner Services MUE Table on the web at:
http://www.cms.gov/Medicare/ Coding/NationalCorrectCodInitEd/MUE.html.
CCI Edits:
NCCI Policy Manual for Medicare Services - Effective January 1, 2014 [ZIP, 749KB]
National Correct Coding
Initiative Policy Manual
Copy of the 1/1/2014 Manual is posted on the DWC website:
for Medicare Services
http://www.dir.ca.gov/dwc/OMFS9904.htm
CCI Edits:
For services rendered on or after January 1, 2014:
Physician CCI Edits
Physician CCI Edits v19.3 (819,852 records). The last row contains edit column 1 = 39599
and column 2 = 49570
Physician CCI Edits v19.3 (710,236 records). The first row contains edit column 1 = 40490
and column 2 = C8950
For services rendered on or after April 15, 2014:
Physician CCI Edits v20.1 effective April 1, 2014 (851,137ds) records). The last row contains edit
column 1 = 39599 and column 2 = 49570
Physician CCI Edits v20.1 effective April 1, 2014 (744,393 records). The first row contains edit
column 1 = 40490 and column 2 = C8950
For services rendered on or after July 1, 2014:
Physician CCI Edits v20.2 effective July 1, 2014 (863,712 records). The last row contains edit
column 1 = 39599 and column 2 = 49570
Physician CCI Edits v20.2 effective July 1, 2014 (752,547 records). The first row contains edit
column 1 = 40490 and column 2 = C8950
For services rendered on or after October 1, 2014:
Physician CCI Edits v20.3 effective October 1, 2014 (864,930 records). The last row contains edit
column 1 = 39599 and column 2 = 49570
Physician CCI Edits v20.3 effective October 1, 2014 (756,576 records). The first row contains edit
column 1 = 40490 and column 2 = C8950
CMS' Medicare National
For services rendered on or after January 1, 2014:
Physician Fee Schedule
RVU14A [Zip]
Relative Value File [Zip]
• RVUPUF14 (Excluding Attachment A)
• PPRRVU14_V1219
• OPPSCAP_V1219
Excluding:
14LOCCO
ANES 2014_V0103
CY 2014 GPCI _12172013
For services rendered on or after April 15, 2014:
RVU14B [Zip]
• RVUPUF14 (Excluding Attachment A)
• PPRRVU14_V0324
• OPPSCAP_V0324
Excluding:
14LOCCO
ANES_2014_V0103
CY 2014 GPCI_12172013
For services rendered on or after July 1, 2014:
RVU14C [Zip 3MB]
• RVUPUF14 (Excluding Attachment A)
• PPRRVU14_V0515
• OPPSCAP_V0515
Excluding:
14LOCCO
ANES 2014_V0103
CY 2014 GPCI_12172013
For services rendered on or after October 1, 2014:
RVU14D [Zip 3MB]
• RVUPUF14 (Excluding Attachment A)
• PPRRVU14_V0815_v4
• OPPSCAP_V0815
Excluding:
14LOCCO
ANES 2014_V0103
CY 2014 GPCI_12172013
CMS Pub 100-04
For services rendered on or after 1/1/2014, use:
Medicare Claims
Transmittal 2837 (Change Request 8523)
Processing: Casting and
Splint Supplies
For services rendered on or after 4/1/2014, use:
the OMFS Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Fee Schedule
applicable to the date of service
Conversion Factors adjusted
Anesthesia Conversion Factor: $33.8190
for MEI and Relative Value
Surgery Conversion Factor: $55.2913
Scale adjustment factor,
Radiology Conversion Factor: $53.1039
if any
Other Services Conversion Factor: $38.3542
Current Procedural
CPT 2014
Terminology (CPT ®)
https://commerce.ama-assn.org/store/
Current Procedural
Do not use CPT codes:
Terminology
27215 (Use G0412 and Surgery CF)
CPT codes that shall not
27216 (Use G0413 and Surgery CF)
be used
27217 (Use G0414 and Surgery CF)
27218 (Use G0415 and Surgery CF)
76140 (see §9789.17.2)
80100 through 80104 (see clinical lab fee schedule, § 9789.50)
90889 (See §9789.14. Use code WC005 code)
97014 (Use G0283 and Other Services CF)
99075 (see Medical-Legal fee schedule, §9795)
99080 (see §9789.14)
99241 through 99245 (see §9789.12.12)
99251 through 99255 (see §9789.12.12)
99455 and 99456.
Diagnostic Cardiovascular
For services rendered on or after January 1, 2014:
Procedure CPT codes
RVU14A, PPRRVU14_V1219, Number “6” in Column labeled “Mult Proc” (Modifier 51) also :
subject to the MPPR
Addendum I, Diagnostic Cardiovascular Services Subject to The Multiple Procedure Payment
Reduction (MPPR) CY 2014 CMS 1600 FC:
http://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-
Regulation-Notices-Items/ CMS-1600-FC.html?DLPage=1&DLSort=3&DLSortDir=descending
For services rendered on or after April 15, 2014:
RVU14B, PPRRVU14_V0324, Number “6” in Column labeled “Mult Proc” (Modifier 51) also
Addendum I, Diagnostic Cardiovascular Services Subject to The Multiple Procedure Payment
Reduction (MPPR) CY 2014 CMS 1600 FC
For services rendered on or after July 1, 2014:
RVU14C, PPRRVU14_V0515, Number “6” in Column labeled “Mult Proc” (Modifier 51) also
Addendum I, Diagnostic Cardiovascular Services Subject to The Multiple Procedure Payment
Reduction (MPPR) CY 2014 CMS 1600 FC
For services rendered on or after October 1, 2014:
RVU14D, PPRRVU14_V0815_v4, Number “6” in
Column labeled “Mult Proc” (Modifier 51) also Addendum I, Diagnostic Cardiovascular Services Subject
to The Multiple Procedure Payment Reduction (MPPR) CY 2014 CMS 1600 FC
Diagnostic Imaging Family
For services rendered on or after January 1, 2014:
Indicator Description
National Physician Fee Schedule Relative Value File Calendar Year 2014
http://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-
Value-Files-Items/RVU14A.html? DLPage=1&DLSort=0&DLSortDir=descending
RVUPUF14 (PDF document)
For services rendered on or after April 15, 2014:
RVU14B, PPRRVU14_V0324, RVUPUF14 (PDF document)
For services rendered on or after July 1, 2014:
RVU14C, PPRRVU14_V0515, RVUPUF14 (PDF document)
For services rendered on or after October 1, 2014:
RVU14D, PPRRVU14_V0815_v4, RVUPUF14 (PDF document)
Diagnostic Imaging Family
For services rendered on or after January 1, 2014:
Indicator for Procedure
RVU14A, PPRRVU14_V1219, column AB, labeled, “Diagnostic Imaging Family Indicator”. Also
Addendum F, Diagnostic Imaging Service Subject to the Multiple Procedure Payment Reduction
(MPPR) CY2014 CMS 1600 FC
For services rendered on or after April 15, 2014:
RVU14B, PPRRVU14_V0324, column AB, labeled, “Diagnostic Imaging Family Indicator”. Also
Addendum F, Diagnostic Imaging Service Subject to the Multiple Procedure Payment Reduction
(MPPR) CY2014 CMS 1600 FC
For services rendered on or after July 1, 2014:
RVU14C, PPRRVU14_V0515, column AB, labeled, “Diagnostic Imaging Family Indicator”. Also
Addendum F, Diagnostic Imaging Service Subject to the Multiple Procedure Payment Reduction
(MPPR) CY2014 CMS 1600 FC
For services rendered on or after October 1, 2014:
RVU14D, PPRRVU14_V0815_v4, column AB, labeled, “Diagnostic Imaging Family Indicator”. Also
Addendum F, Diagnostic Imaging Service Subject to the Multiple Procedure Payment Reduction
(MPPR) CY2014 CMS 1600 FC
DWC Pharmaceutical
http://www.dir.ca.gov/dwc/OMFS9904.htm
Fee Schedule
Geographic Health
2014 Primary Care HPSA [ZIP, 97KB]
Professional Shortage Area
zip code data files
2014 Mental Health HPSA [ZIP, 222KB]
Health Resources and
Services Administration:
Geographic HPSA shortage
area query
(By State & County)
http://hpsafind.hrsa.gov/
(By Address)
http://datawarehouse.hrsa.gov/ geoHPSAAdvisor/GeographicHPSAAdvisor.aspx
Incident To Codes
For services rendered on or after January 1, 2014:
RVU14A, PPRRVU14_V1219, with PC/TC indicator number “5”
For services rendered on or after April 15, 2014:
RVU14B, PPRRVU14_V0324, with PC/TC indicator number “5”
For services rendered on or after July 1, 2014:
RVU14C, PPRRVU14_V0515, with PC/TC indicator number “5”
For services rendered on or after October 1, 2014:
RVU14D, PPRRVU14_V0815_v4, with PC/TC indicator number “5”
Medi-Cal Rates - DHCS
For services rendered on or after 1/1/2014, use:
Medi-Cal Rates file - Updated 12/15/2013
For services rendered on or after 1/23/2014, use:
Medi-Cal Rates file - Updated 1/15/2014
For services rendered on or after 2/15/2014, use:
Medi-Cal Rates file - Updated 2/15/2014
For services rendered on or after 3/15/2014, use:
Medi-Cal Rates file - Updated 3/15/2014
For services rendered on or after 6/15/2014, use:
Medi-Cal Rates file - Updated 6/15/2014
For services rendered on or after 7/15/2014, use:
Medi-Cal Rates file - Updated 7/15/2014
For services rendered on or after 8/15/2014, use:
Medi-Cal Rates file - Updated 8/15/2014
For services rendered on or after 9/15/2014, use:
Medi-Cal Rates file - Updated 9/15/2014
For services rendered on or after 10/15/2014, use:
Medi-Cal Rates file - Updated 10/15/2014
For services rendered on or after 11/15/2014, use:
Medi-Cal Rates file - Updated 11/15/2014
For services rendered on or after 12/15/2014, use:
Medi-Cal Rates file - Updated 12/15/2014
For services rendered on or after 1/15/2015, use:
Medi-Cal Rates file - Updated 1/15/2015
For services rendered on or after 2/15/2015, use:
Medi-Cal Rates file - Updated 2/15/2015
Copies of the Medi-Cal Rates files (without CPT descriptors) are posted on the DWC website:
http://www.dir.ca.gov/dwc/OMFS9904.htm
Ophthalmology Procedure
For services rendered on or after January 1, 2014:
CPT codes subject to
RVU14A, PPRRVU14_V1219, Number “7” in Column labeled “Multiple Procedure (Modifier 51). Also
the MPPR
Addendum J, Diagnostic Ophthalmology Services Subject to the Multiple Procedure Payment Reduction
(MPPR) CY 2014 CMS 1600 FC
For services rendered on or after April 15, 2014:
RVU14B, PPRRVU14_V0324, Number “7” in Column labeled “Multiple Procedure (Modifier 51). Also
Addendum J, Diagnostic Ophthalmology Services Subject to the Multiple Procedure Payment Reduction
(MPPR) CY 2014 CMS 1600 FC
For services rendered on or after July 1, 2014:
RVU14C, PPRRVU14_V0515, Number “7” in Column labeled “Multiple Procedure (Modifier 51). Also
Addendum J, Diagnostic Ophthalmology Services Subject to the Multiple Procedure Payment Reduction
(MPPR) CY 2014 CMS 1600 FC
For services rendered on or after October 1, 2014:
RVU14D, PPRRVU14_V0815_v4, Number “7” in Column labeled “Multiple Procedure (Modifier 51). Also
Addendum J, Diagnostic Ophthalmology Services Subject to the Multiple Procedure Payment Reduction
(MPPR) CY 2014 CMS 1600 FC
Physical Therapy Multiple
For services rendered on or after January 1, 2014:
Procedure Payment
RVU14A, PPRRVU14_V1219, Number “5” in Column labeled “Mult Proc”. Also Addendum H, Separately
Reduction: “Always
Payable Always Therapy Services Subject to the Multiple Procedure Payment Reduction (MPPR) CY
Therapy” Codes; and
2014 CMS 1600 FC
Acupuncture and
Chiropractic Codes
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
For services rendered on or after April 15, 2014:
RVU14B, PPRRVU14_V0324 , Number “5” in Column labeled “Mult Proc”. Also Addendum H, Separately
Payable Always Therapy Services Subject to the Multiple Procedure Payment Reduction (MPPR)
CY 2014 CMS 1600 FC
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
For services rendered on or after July 1, 2014:
RVU14C, PPRRVU14_V0515 , Number “5” in Column labeled “Mult Proc”. Also Addendum H, Separately
Payable Always Therapy Services Subject to the Multiple Procedure Payment Reduction (MPPR) CY
2014 CMS 1600 FC
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
For services rendered on or after October 1, 2014:
RVU14D, PPRRVU14_V0815_v4 , Number “5” in Column labeled “Mult Proc”. Also Addendum H, Separately
Payable Always Therapy Services Subject to the Multiple Procedure Payment Reduction (MPPR) CY
2014 CMS 1600 FC
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
Physician Time
CY 2014 PFS Physician Time [ZIP, 504KB]
Radiology Diagnostic
For services rendered on or after January 1, 2014:
Imaging Multiple
RVU14A, PPRRVU14_V1219, number “4” in column S, labeled, “Mult Proc”.
Procedures
For services rendered on or after April 15, 2014:
RVU14B, PPRRVU14_V0324 , number “4” in column S, labeled, “Mult Proc”
For services rendered on or after July 1, 2014:
RVU14C, PPRRVU14_V0515 , number “4” in column S, labeled, “Mult Proc”
For services rendered on or after October 1, 2014:
RVU14D, PPRRVU14_V0815_v4 , number “4” in
column S, labeled, “Mult Proc”
Statewide GAFs
Average Statewide Work GAF: 1.040
(Other than anesthesia)
Average Statewide Practice Expense GAF: 1.1606
Average Statewide Malpractice Expense GAF: 0.6636
Statewide GAF (Anesthesia)
Average Statewide Anesthesia GAF: 1.0313
The 1995 Documentation
https://www.cms.gov/ Outreach-and-Education/Medicare-Learning-
Guidelines for Evaluation &
Network-MLN/ MLNEdWebGuide/Downloads/95Docguidelines.pdf
Management Services
The 1997 Documentation
https://www.cms.gov/ Outreach-and-Education/Medicare-Learning-
Guidelines for Evaluation
Network-MLN/ MLNEdWebGuide/Downloads/97Docguidelines.pdf.
and Management Services
(b) Services Rendered On or After 3/1/2015. Documents listed in the following table are incorporated by reference and will be made available upon request to the Administrative Director.
Document/Data
Services Rendered On or After March 1, 2015 & Mid-year Updates
Adjustment Factors
For all services other than anesthesia:
(These factors have been
2015 Cumulative Relative Value Scale adjustment factor: 1.0703
incorporated into the
[2015 annual adjustment factor x 2014 cumulative adjustment factor = 2015 cumulative adjustment
conversion factors listed
factor (1.006 x 1.0638 = 1.0703)]
below)
2015 RVS adjustment factor
2015 Annual increase in the MEI: 1.008
2015 Annual adjustment factor: 1.006 (0.9981 x 1.008)
For anesthesia services:
2015 Anesthesia cumulative adjustment factor: 1.0461
[2015 anesthesia annual adjustment factor x 2014 anesthesia cumulative adjustment factor = 2015 cumulative adjustment factor (1.001 x 1.0449 = 1.0461)]
2015 Total RVS adjustment factor†: 0.9932
2015 RVU budget neutrality factor: 0.9981
2015 Anesthesia practice expense adjustment factor: 0.99506
2015 Annual increase in the MEI: 1.008
2015 Anesthesia annual adjustment factor: 1.001
[BN RVU x Anesthesia PE Adjustment x MEI = (0.9981 x 0.99506 x 1.008 ) = 1.001]
†RVS adjustment factor for 2015 is 1) the RVU budget neutrality adjustment factor for “all services other
than anesthesia”; and 2) the product of RVU budget neutrality adjustment factor and the anesthesia practice
expense adjustment factor for anesthesia services.
Anesthesia Base Units by
2014anesBASEfin
CPT Code
California-Specific Codes
WC001 - Not reimbursable
WC002 - $ 12.01
WC003 - $38.99 for first page
$23.99 each additional page. Maximum of six pages absent mutual agreement ($158.94)
WC004 - $38.99 for first page
$23.99 each additional page. Maximum of seven pages absent mutual agreement ($182.93)
WC005 - $38.99 for first page, $23.99 each additional page. Maximum of six pages absent mutual
agreement ($158.94)
WC007 - $38.99 for first page
$23.99 each additional page. Maximum of six pages absent mutual agreement ($158.94)
WC008 - $10.34 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages.
WC009 - $10.34 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages.
WC010 - $5.17 per x-ray
WC011 - $10.34 per scan
WC012 - No Fee Prescribed / Non Reimbursable absent agreement
CCI Edits:
For services rendered on or after March 1, 2015, use:
Medically Unlikely Edits
“Practitioner Services MUE Table - Effective 1/1/2015.”
For services rendered on or after April 1, 2015, use:
“Practitioner Services MUE Table - Effective 4/1/2015.”
For services rendered on or after July 1, 2015, use:
“Practitioner Services MUE Table - Effective 7/1/2015.”
For services rendered on or after October 1, 2015, use:
“Practitioner Services MUE Table - Effective 10/1/2015.”
Copies of the MUE Tables are posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm
CMS posts only the most recent version of the Practitioner Services MUE Table on the web at:
http://www.cms.gov/Medicare/ Coding/NationalCorrectCodInitEd/MUE.html.
CCI Edits:
For services rendered on or after March 1, 2015:
National Correct Coding
“NCCI Policy Manual for Medicare Services - Effective January 1, 2015 [ZIP, 1MB]”
Initiative Policy Manual
for Medicare Services
Copy of the 2015 Manual is posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm#7
CCI Edits:
For services rendered on or after March 1, 2015:
Physician CCI Edits
Physician CCI Edits v21.0 effective January 1, 2015 (898,800 records). The last row contains edit
(Practitioner PTP Edits)
column 1 = 39599 and column 2 = 49570
Physician CCI Edits v21.0 effective January 1, 2015 (787,357 records). The first row contains edit
column 1 = 40490 and column 2 = C8950
For services rendered on or after April 1, 2015:
Practitioner PTP Edits v21.1 effective April 1, 2015 (899,747 records ). The last row contains edits
column 1 = 39599 and column 2 = 49570
Practitioner PTP Edits v21.1 effective April 1, 2015 (787,520 records ). The first row contains edits
column 1 = 40490 and column 2 = C8950
For services rendered on or after July 1, 2015:
Practitioner PTP Edits v21.2 effective July 1, 2015 (872,404 records ). The last row contains edits
column 1 = 39599 and column 2 = 49570
Practitioner PTP Edits v21.2 effective July 1, 2015 (821,537 records ). The first row contains edits
column 1 = 40490 and column 2 = 00170
For services rendered on or after October 1, 2015:
Practitioner PTP Edits v21.3 effective October 1, 2015 (880,855 records). The last row contains edits
column 1 = 39599 and column 2 = 49570
Practitioner PTP Edits v21.3 effective October 1, 2015 (832,093 records). The first row contains edits
column 1 = 40490 and column 2 = 00170
Access the Physician CCI Edits on the CMS website:
http://www.cms.gov/Medicare/ Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html
Note: the Physician CCI Edits excel file maintained by CMS contains effective date and deletion date (if
any) for each column 1/column 2 pair. Therefore, the most recent file is the only file posted on the CMS
website, and covers all time periods.
CMS' Medicare National
For services rendered on or after March 1, 2015:
Physician Fee Schedule
RVU15A (Updated 01/08/15) [ZIP, 2MB]
Relative Value File [Zip]
• RVUPUF15 (Excluding Attachment A)
• PPRRVU15_V1223c
• OPPSCAP_V1223
Excluding:
15LOCCO
ANES 2015_V122314
CY2015_GPCIs
For services rendered on or after May 1, 2015:
RVU15B [ZIP, 3MB]
• RVUPUF15 (Excluding Attachment A)
• PPRRVU15_V0213_Current
• OPPSCAP_V0217
Excluding:
15LOCCO
Anes_2015_122314
Anes_Conv_122314_fmt
CY2015_GPCIs
For services rendered on or after July 1, 2015:
RVU15C [ZIP, 5MB] (Except the 0.5% update is not adopted)
• RVUPUF15 (Excluding Attachment A)
• PPRRVU15_UP05_V0622
• OPPSCAP_UP05_V0619
Excluding:
15LOCCO
Anes_2015_122314
ANES_2015_UP05_V0701
CY2015_GPCIs
PPRRVU15_UP0.V0515
OPPSCAP_UP0_V0515
For services rendered on or after October 1, 2015:
RVU15D [ZIP, 5MB] (Except the 0.5% update is not adopted)
• RVUPUF15 (Excluding Attachment A)
• PPRRVU15_OCT05_V1001
• OPPSCAP_UP05_V0815
Excluding:
15LOCCO
Anes_2015_122314
ANES_2015_UP05_V0701
CY2015_GPCIs
OPPSCAP_UP0_V0815
PPRRVU15_OCT_V1001
Conversion Factors adjusted
Anesthesia Conversion Factor: $31.5290
for MEI and Relative Value
Surgery Conversion Factor: $51.6570
Scale adjustment factor
Radiology Conversion Factor: $50.1900
Other Services Conversion Factor: $40.2970
Current Procedural
CPT 2015
Terminology (CPT ®)
https://commerce.ama-assn.org/store/
Current Procedural
Do not use CPT codes:
Terminology
27215 (Use G0412 and Surgery CF)
CPT codes that shall
27216 (Use G0413 and Surgery CF)
not be used
27217 (Use G0414 and Surgery CF)
27218 (Use G0415 and Surgery CF)
76140 (see §9789.17.2)
90889 (See §9789.14. Use code WC005 code)
97014 (Use G0283 and Other Services CF)
99075 (see Medical-Legal fee schedule, §9795)
99080 (see §9789.14)
99241 through 99245 (see §9789.12.12)
99251 through 99255 (see §9789.12.12)
99455 and 99456.
Diagnostic Cardiovascular
For services rendered on or after March 1, 2015:
Procedure CPT codes
RVU15A, PPRRVU15_V1223c, Number “6” in Column labeled “Mult Proc” (Modifier 51), also listed
subject to the MPPR
in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction Files [Zip, 44KB], in the
document CY_2015_PFS_1612-F_ Diagnostic Cardiovascular Services Subject To the Multiple Procedure
Payment Reduction (MPPR)
For services rendered on or after May 1, 2015:
RVU15B, PPRRVU15_V0213_Current, Number “6” in Column labeled “Mult Proc” (Modifier 51), also listed
in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction Files [Zip, 44KB], in the document
CY_2015_PFS_1612-F_ Diagnostic Cardiovascular Services Subject To the Multiple Procedure Payment
Reduction (MPPR)
For services rendered on or after July 1, 2015:
RVU15C, PPRRVU15_UP05_V0622, Number “6” in Column labeled “Mult Proc” (Modifier 51), also listed
in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction Files [Zip, 44KB], in the document
CY_2015_PFS_1612-F_ Diagnostic Cardiovascular Services Subject To the Multiple Procedure Payment
Reduction (MPPR)
For services rendered on or after October 1, 2015:
RVU15D, PPRRVU15_OCT05_V1001, Number “6” in Column labeled “Mult Proc” (Modifier 51), also listed in
CY 2015 PFS Final Rule Multiple Procedure Payment Reduction Files [Zip, 44KB], in the document
CY_2015_PFS_1612-F_ Diagnostic Cardiovascular Services Subject To the Multiple Procedure Payment
Reduction (MPPR)
Diagnostic Imaging Family
For services rendered on or after March 1, 2015:
Indicator Description
Diagnostic Imaging Family Indicator:
88 = Subject to the reduction
99 = Concept does not apply
RVU15A, RVUPUF15 (PDF document)
For services rendered on or after May 1, 2015:
Diagnostic Imaging Family Indicator:
88 = Subject to the reduction
99 = Concept does not apply
RVU15B, RVUPUF15 (PDF document)
For services rendered on or after July 1, 2015:
Diagnostic Imaging Family Indicator:
88 = Subject to the reduction
99 = Concept does not apply
RVU15C, RVUPUF15 (PDF document)
For services rendered on or after October 1, 2015:
Diagnostic Imaging Family Indicator:
88 = Subject to the reduction
99 = Concept does not apply
RVU15D, RVUPUF15 (PDF document)
Diagnostic Imaging Family
For services rendered on or after March 1, 2015:
Procedures Subject to the
RVU15A, PPRRVU15_V1223c, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator”,
MPPR
also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document
CY_2015_PFS_1612-F_Diagnostic Imaging Services Subject To the Multiple Procedure Payment Reduction
(MPPR)
For services rendered on or after May 1, 2015:
RVU15B, PPRRVU15_V0213_Current, number “88” in column AB, labeled, “Diagnostic Imaging Family
Indicator”, also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in
the document CY_2015_PFS_1612-F_Diagnostic Imaging Services Subject To the Multiple Procedure Payment
Reduction (MPPR)
For services rendered on or after July 1, 2015:
RVU15C, PPRRVU15_UP05_V0622, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator”,
also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document
CY_2015_PFS_1612-F_Diagnostic Imaging Services Subject To the Multiple Procedure Payment Reduction
(MPPR)
For services rendered on or after October 1, 2015:
RVU15D, PPRRVU15_OCT05_V1001, number “88” in column AB, labeled, “Diagnostic Imaging Family
Indicator”, also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in
the document CY_2015_PFS_1612-F_Diagnostic Imaging Services Subject To the Multiple Procedure Payment
Reduction (MPPR)
Diagnostic Imaging
For services rendered on or after March 1, 2015:
Multiple Procedures
RVU15A, PPRRVU15_V1223c, number “4” in column S, labeled, “Mult Proc”, also listed in CY
Subject to the MPPR
2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document
CY_2015_PFS_1612-F_Diagnostic Imaging Services Subject To the Multiple Procedure Payment
Reduction (MPPR)
For services rendered on or after May 1, 2015:
RVU15B, PPRRVU15_V0213_Current, number “4” in
column S, labeled, “Mult Proc”, also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction
File [Zip, 44KB], in the document CY_2015_PFS_1612-F_Diagnostic Imaging Services Subject To
the Multiple Procedure Payment Reduction (MPPR)
For services rendered on or after July 1, 2015:
RVU15C, PPRRVU15_UP05_V0622, number “4” in column S, labeled, “Mult Proc”, also listed in CY
2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document
CY_2015_PFS_1612-F_Diagnostic Imaging Services Subject To the Multiple Procedure Payment
Reduction (MPPR)
For services rendered on or after October 1, 2015:
RVU15D, PPRRVU15_OCT05_V1001, number “4” in column S, labeled, “Mult Proc”, also listed in CY
2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document
CY_2015_PFS_1612-F_Diagnostic Imaging Services Subject To the Multiple Procedure Payment
Reduction (MPPR)
DWC Pharmaceutical Fee
http://www.dir.ca.gov/dwc/OMFS9904.htm#8
Schedule
Geographic Health
2015 Primary Care HPSA [ZIP, 88KB]
Professional Shortage Area
2015 Mental Health HPSA [ZIP, 185KB]
code data files
Health Resources and
Services Administration:
Geographic HPSA shortage
area query
(By State & County)
http://hpsafind.hrsa.gov/
(By Address)
http://datawarehouse.hrsa.gov/ geoHPSAAdvisor/GeographicHPSAAdvisor.aspx
Incident To Codes
For services rendered on or after March 1, 2015:
RVU15A, PPRRVU15_V1223c, with PC/TC indicator number “5”
For services rendered on or after May 1, 2015:
RVU15B, PPRRVU15_V0213_Current, with PC/TC indicator number “5”
For services rendered on or after July 1, 2015:
RVU15C, PPRRVU15_UP05_V0622, with PC/TC indicator number “5”
For services rendered on or after October 1, 2015:
RVU15D, PPRRVU15_OCT05_V1001, with PC/TC indicator number “5”
Medi-Cal Rates - DHCS
Pursuant to section 9789.13.2, the Medi-Cal Rates file's “Basic Rate” is used in calculating maximum
fee for physician-administered drugs, biologicals, vaccines or blood products, by date of service.
For services rendered on or after March 1, 2015, use:
Medi-Cal Rates file - Updated 2/15/2015
For services rendered on or after March 15, 2015, use:
Medi-Cal Rates file - Updated 3/15/2015
For services rendered on or after April 15, 2015, use:
Medi-Cal Rates file - Updated 4/15/2015
For services rendered on or after May 15, 2015, use:
Medi-Cal Rates file - Updated 5/15/2015
For services rendered on or after June 15, 2015, use:
Medi-Cal Rates file - Updated 6/15/2015
For services rendered on or after July 15, 2015, use:
Medi-Cal Rates file - Updated 7/15/2015
For services rendered on or after August 15, 2015, use:
Medi-Cal Rates file - Updated 8/15/2015
For services rendered on or after September 15, 2015, use:
Medi-Cal Rates file - Updated 9/15/2015
For services rendered on or after October 15, 2015, use:
Medi-Cal Rates file - Updated 10/15/2015
For services rendered on or after November 15, 2015, use:
Medi-Cal Rates file - Updated 11/15/2015
For services rendered on or after December 15, 2015, use:
Medi-Cal Rates file - Updated 12/15/2015
Copies of the Medi-Cal Rates files (without CPT descriptors) are posted on the DWC website:
http://www.dir.ca.gov/dwc/OMFS9904.htm
Ophthalmology Procedure
For services rendered on or after March 1, 2015:
CPT codes subject to the
RVU15A, PPRRVU15_V1223c, Number “7” in Column labeled “Mult Proc” (Modifier 51). Also listed
MPPR
in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the
document CY_2015_PFS_1612-F Diagnostic Ophthalmology Services Subject to the Multiple Procedure
Payment Reduction (MPPR)
For services rendered on or after May 1, 2015:
RVU15B, PPRRVU15_V0213_Current, Number “7” in Column labeled “Mult Proc” (Modifier 51). Also listed
in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document
CY_2015_PFS_1612-F Diagnostic Ophthalmology Services Subject to the Multiple Procedure Payment
Reduction (MPPR)
For services rendered on or after July 1, 2015:
RVU15C, PPRRVU15_UP05_V0622, Number “7” in Column labeled “Mult Proc” (Modifier 51). Also listed
in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the
document CY_2015_PFS_1612-F Diagnostic Ophthalmology Services Subject to the Multiple Procedure
Payment Reduction (MPPR)
For services rendered on or after October 1, 2015:
RVU15D, PPRRVU15_OCT05_V1001, Number “7” in Column labeled “Mult Proc” (Modifier 51). Also
listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the
document CY_2015_PFS_1612-F Diagnostic Ophthalmology Services Subject to the Multiple Procedure
Payment Reduction (MPPR)
Physical Therapy Multiple
For services rendered on or after March 1, 2015:
Procedure Payment
RVU15A, PPRRVU15_V1223c, Number “5” in Column labeled “Mult Proc”. Also listed in the CY
Reduction: “Always
2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB] in the
Therapy” Codes; and
document CY_2015_PFS_1612-F Separately Payable Always Therapy Services Subject to the Multiple
Acupuncture and
Procedure Payment Reduction (MPPR)
Chiropractic Codes
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
For services rendered on or after May 1, 2015:
RVU15B, PPRRVU15_V0213_Current, Number “5” in Column labeled “Mult Proc”. Also listed in the CY
2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB] in the document
CY_2015_PFS_1612-F Separately Payable Always Therapy Services Subject to the Multiple Procedure
Payment Reduction (MPPR)
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
For services rendered on or after July 1, 2015:
RVU15C, PPRRVU15_UP05_V0622, Number “5” in Column labeled “Mult Proc”. Also listed in the CY 2015
PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB] in the document CY_2015_PFS_1612-F
Separately Payable Always Therapy Services Subject to the Multiple Procedure Payment Reduction (MPPR)
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
For services rendered on or after October 1, 2015:
RVU15D, PPRRVU15_OCT05_V1001, Number “5” in Column labeled “Mult Proc”. Also listed in the CY 2015
PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB] in the document CY_2015_PFS_1612-F
Separately Payable Always Therapy Services Subject to the Multiple Procedure Payment Reduction (MPPR)
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
Physician Time
CY 2015 PFS Final Rule Physician Time Updated 01/20/15 [ZIP 478KB]
Statewide GAFs (Other
Average Statewide Work GAF: 1.0420
than anesthesia)
Average Statewide Practice Expense GAF: 1.1621
Average Statewide Malpractice Expense GAF: 0.7388
Statewide GAF (Anesthesia)
Average Statewide Anesthesia GAF: 1.0391
Splints and Casting Supplies
For services rendered on or after March 1, 2015, use:
The OMFS Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Fee Schedule
applicable to the date of service.
The 1995 Documentation
https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNEdWebGuide/
Guidelines for Evaluation
Downloads/95Docguidelines.pdf
& Management Services
The 1997 Documentation
https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNEdWebGuide/
Guidelines for Evaluation
Downloads/97Docguidelines.pdf.
and Management
Services
(c) Services Rendered On or After 1/1/2016. Documents listed in the following table are incorporated by reference and will be made available upon request to the Administrative Director.
Document/Data
Services Rendered On or After January 1, 2016 & Mid-year Updates
Adjustment Factors (These
For services rendered on or after January 1, 2016:
factors have been
For all services other than anesthesia
incorporated into the
2016 Cumulative adjustment factor: 1.0818
conversion factors listed
2016 RVU budget neutrality adjustment factor: 0.9998
below)
2016 Annual increase in the MEI: 1.011
2015 Cumulative “other than anesthesia” adjustment 1.0703
For anesthesia services:
2016 Cumulative anesthesia adjustment factor: 1.0527
2016 RVU budget neutrality adjustment factor: 0.9998
2016 Anesthesia Practice Expense and Malpractice adjustment factor: 0.99555
2016 Annual increase in the MEI: 1.011
2015 Cumulative anesthesia adjustment: 1.0461
For services rendered on or after April 1, 2016:
For all services other than anesthesia:
2016 Cumulative adjustment factor: 1.0812
2016 RVU budget neutrality adjustment factor: 0.99924
2016 Annual increase in the MEI: 1.011
2015 Cumulative
For anesthesia services:
2016 Cumulative anesthesia adjustment factor: 1.0317
2016 RVU budget neutrality adjustment factor: : 0.99924
2016 Anesthesia Practice Expense and Malpractice adjustment factor: 0.97628
2016 Annual increase in the MEI: 1.011
2015 Cumulative anesthesia adjustment: 1.0461
Anesthesia Base Units by
2014anesBASEfin
CPT Code
California-Specific Codes
WC001 - Not reimbursable
WC002 - $ 12.14
WC003 - $39.42 for first page
$24.25 each additional page. Maximum of six pages absent mutual agreement ($160.69)
WC004 - $39.42 for first page
$24.25 each additional page. Maximum of seven pages absent mutual agreement ($184.94)
WC005 - $39.42 for first page, $24.25 each additional page. Maximum of six pages absent
mutual agreement ($160.69)
WC007 - $39.42 for first page
$24.25 each additional page. Maximum of six pages absent mutual agreement ($160.69)
WC008 - $10.45 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages.
WC009 - $10.45 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages.
WC010 - $5.23 per x-ray
WC011 - $10.45 per scan
WC012 - No Fee Prescribed / Non Reimbursable absent agreement
CCI Edits:
For services rendered on or after January 1, 2016, use:
Medically Unlikely Edits
“Practitioner Services MUE Table - Effective 1/1/2016.”
For services rendered on or after April 1, 2016, use:
“Practitioner Services MUE Table - Effective 4/1/2016.”
For services rendered on or after July 1, 2016, use:
“Practitioner Services MUE Table - Effective 7/1/2016.”
For services rendered on or after October 1, 2016, use:
“Practitioner Services MUE Table - Effective 10/1/2016.”
Copies of the MUE Tables are posted on the DWC website:
http://www.dir.ca.gov/dwc/OMFS9904.htm
CMS posts only the most recent version of the Practitioner Services MUE Table on the web at:
http://www.cms.gov/Medicare /Coding/NationalCorrectCodInitEd/MUE.html
CCI Edits:
For services rendered on or after January 1, 2016:
National Correct Coding
“NCCI Policy Manual for Medicare Services - Effective January 1, 2016 [ZIP, 761MB]”
Initiative Policy Manual for
Medicare Services
Copy of the 2016 Manual is posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm#7
CCI Edits:
Physician CCI Edits
For services rendered on or after January 1, 2016:
(Practitioner PTP Edits)
Practitioner PTP Edits v22.0 effective January 1, 2016 (903,287 records). The last row contains edits
column 1 = 39599 and column 2 = 49570
Practitioner PTP Edits v22.0 effective January 1, 2016 (866,823 records). The first row contains edits
column 1 = 40490 and column 2 = 00170
For services rendered on or after April 1, 2016:
Practitioner PTP Edits v22.1 effective April 1, 2016 (914,985 records). The last row contains edits
column 1 = 39599 and column 2 = 49570
Practitioner PTP Edits v22.1 effective April 1, 2016 (877,109 records). The first row contains edits
column 1 = 40490 and column 2 = 00170
For services rendered on or after July 1, 2016:
Practitioner PTP Edits v22.2 effective July 1, 2016 (915,436 records). The last row contains edits
column 1 = 39599 and column 2 = 49570
Practitioner PTP Edits v22.2 effective July 1, 2016 (877,847 records). The first row contains edits
column 1 = 40490 and column 2 = 00170
For services rendered on or after October 1, 2016:
Practitioner PTP Edits v22.3 effective October 1, 2016 (668,511 records) 0001M/36591 - 29999/G0354
Practitioner PTP Edits v22.3 effective October 1, 2016 (498,018 records) 30000/0213T - 49999/49570
Practitioner PTP Edits v22.3 effective October 1, 2016 (489,682 records) 50010/0213T - 79999/90784
Practitioner PTP Edits v22.3 effective October 1, 2016 (179,162 records) 80003/80002 - R0075/R0070
Access the Physician CCI Edits on the CMS website:
http://www.cms.gov/Medicare /Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html
Note: the Physician CCI Edits excel file maintained by CMS contains effective date and deletion date (if any)
for each column 1/column 2 pair. Therefore, the most recent file is the only file posted on the CMS website,
and covers all time periods.
CMS' Medicare National
For services rendered on or after January 1, 2016:
Physician Fee Schedule
RVU16A (Released January 2016) [ZIP, 3MB]
Relative Value File [Zip]
• RVUPUF16 (Excluding Attachment A)
• PPRRVU16_V0122
• OPPSCAP_V0105
Excluding:
16LOCCO
ANES_V0105
CY2016_GPCIs
For services rendered on or after April 1, 2016:
RVU16B (April 2016 release) [ZIP, 3MB]
• RVUPUF16 (Excluding Attachment A)
• PPRRVU16_April_V0202
• OPPSCAP_V0215
Excluding:
16LOCCO
ANES_V0105
CY2016_GPCIs
For services rendered on or after July 1, 2016:
RVU16C (July 2016 release) [ZIP, 3MB]
• RVUPUF16 (Excluding Attachment A)
• PPRRVU16_V0517
• OPPSCAP_V0515
Excluding:
16LOCCO
ANES_V0105
CY2016_GPCIs
For services rendered on or after October 1, 2016:
RVU16D [ZIP, 3MB]
• RVUPUF16 (Excluding Attachment A)
• PPRRVU16_V0804
• OPPSCAP_V0815
Excluding:
16LOCCO
ANES_V0105
CY2016_GPCIs
Conversion Factors adjusted
For services rendered on or after January 1, 2016:
for MEI and Relative Value
Anesthesia Conversion Factor: $29.3852
Scale adjustment factor
Surgery Conversion Factor: $48.2013
Radiology Conversion Factor: $47.4598
Other Services Conversion Factor: $42.4599
For services rendered on or after April 1, 2016:
Anesthesia Conversion Factor: $28.8003
Surgery Conversion Factor: $48.1743
Radiology Conversion Factor: $47.4332
Other Services Conversion Factor: $42.4361
Current Procedural
CPT 2016
Terminology (CPT®)
https://commerce.ama-assn.org/store/
Current Procedural
Do not use CPT codes:
Terminology
27215 (Use G0412 and Surgery CF)
CPT codes that shall not
27216 (Use G0413 and Surgery CF)
be used
27217 (Use G0414 and Surgery CF)
27218 (Use G0415 and Surgery CF)
76140 (see §9789.17.2)
90889 (See §9789.14. Use codeWC005 code)
97014 (Use G0283 and Other Services CF)
99075 (see Medical-Legal fee schedule, §9795)
99080 (see §9789.14)
99241 through 99245 (see §9789.12.12)
99251 through 99255 (see §9789.12.12)
99455 and 99456
Diagnostic Cardiovascular
For services rendered on or after January 1, 2016:
Procedure CPT codes
RVU16A, PPRRVU16_V0122, Number “6” in column S, labeled “Mult Proc” (Modifier 51), also listed
subject to the MPPR
in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction Files [Zip, 39KB], in the
document CMS-1631-FC_Diagnostic Cardiovascular Services Subject to MPPR
For services rendered on or after April 1, 2016:
RVU16B, PPRRVU16_April_V0202, Number “6” in column S, labeled “Mult Proc” (Modifier 51), also listed in CY
2016 PFS Final Rule Multiple Procedure Payment Reduction Files [Zip, 39KB], in the document CMS-1631-FC_
Diagnostic Cardiovascular Services Subject to MPPR
For services rendered on or after July 1, 2016:
RVU16C, PPRRVU16_V0517, Number “6” in column S, labeled “Mult Proc” (Modifier 51), also listed in CY 2016
PFS Final Rule Multiple Procedure Payment Reduction Files [Zip, 39KB], in the document CMS-1631-FC_
Diagnostic Cardiovascular Services Subject to MPPR
For services rendered on or after October 1, 2016:
RVU16D, PPRRVU16_V0804, Number “6” in column S, labeled “Mult Proc” (Modifier 51), also listed in CY 2016
PFS Final Rule Multiple Procedure Payment Reduction Files [Zip, 39KB], in the document CMS-1631-FC_
Diagnostic Cardiovascular Services Subject to MPPR
Diagnostic Imaging Family
For services rendered on or after January 1, 2016:
Indicator Description
Diagnostic Imaging Family Indicator:
88 = Subject to the reduction
99 = Concept does not apply
RVU16A, RVUPUF16 (PDF document)
For services rendered on or after April 1, 2016:
Diagnostic Imaging Family Indicator:
88 = Subject to the reduction
99 = Concept does not apply
RVU16B, RVUPUF16 (PDF document)
For services rendered on or after July 1, 2016:
Diagnostic Imaging Family Indicator:
88 = Subject to the reduction
99 = Concept does not apply
RVU16C, RVUPUF16 (PDF document)
For services rendered on or after October 1, 2016:
Diagnostic Imaging Family Indicator:
88 = Subject to the reduction
99 = Concept does not apply
RVU16D, RVUPUF16 (PDF document)
Diagnostic Imaging Family
For services rendered on or after January 1, 2016:
Procedures Subject to
RVU16A, PPRRVU16_V0122, number “88” in column AB, labeled, “Diagnostic Imaging Family
the MPPR
Indicator”, also listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB],
in the document CMS-1631-FC_Diagnostic Imaging Services Subject to MPPR
For services rendered on or after April 1, 2016:
RVU16B, PPRRVU16l_V0202, number “88” in column AB, lableled, “Diagnostic Imaging Family
Indicator”, also listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [ZIP, 39 KB], in the
document CMS-1631-FC_Diagnostic Imaging Services Subject to MPPR
For services rendered on or after July 1, 2016:
RVU16C, PPRRVU16_V0517, number “88” in column AB, lableled, “Diagnostic Imaging Family Indicator”,
also listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [ZIP, 39 KB], in the document
CMS-1631-FC_Diagnostic Imaging Services Subject to MPPR
For services rendered on or after October 1, 2016:
RVU16D, PPRRVU16_V0804, number “88” in column AB, lableled, “Diagnostic Imaging Family Indicator”,
also listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [ZIP, 39 KB], in the document
CMS-1631-FC_Diagnostic Imaging Services Subject to MPPR
Diagnostic Imaging Multiple
For services rendered on or after January 1, 2016:
Procedures Subject to the
RVU16A, PPRRVU16_V0122, number “4” in column S, labeled, “Mult Proc”, also listed in CY 2016 PFS
MPPR
Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB], in the document CMS-1631-FC_Diagnostic
Imaging Services Subject to MPPR
For services rendered on or after April 1, 2016:
RVU16B, PPRRVU16_April_V0202, number “4” in column S, labled, “Mult Proc”, also listed in CY 2016 PFS
Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB], in the document CMS-1631-FC_Diagnostic
Imaging Services Subject to MPPR
For services rendered on or after July 1, 2016:
RVU16C, PPRRVU16_V0517, number “4” in column S, labled, “Mult Proc”, also listed in CY 2016 PFS
Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB], in the document CMS-1631-FC_Diagnostic
Imaging Services Subject to MPPR
For services rendered on or after October 1, 2016:
RVU16D, PPRRVU16_V0804, number “4” in column S, labled, “Mult Proc”, also listed in CY 2016 PFS
Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB], in the document CMS-1631-FC_Diagnostic
Imaging Services Subject to MPPR
DWC Pharmaceutical Fee
http://www.dir.ca.gov/dwc/OMFS9904.htm#8
Schedule
Geographic Health
2016 Primary Care HPSA [ZIP, 99KB]
Professional Shortage Area
2016 Mental Health HPSA [ZIP, 239KB]
zip code data files
Access the files on the CMS website:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HPSAPSAPhysicianBonuses /index.html?redirect=/hpsapsaphysicianbonuses/
Health Resources and
Services Administration:
Geographic HPSA shortage
area query
(By State & County)
http://hpsafind.hrsa.gov/
(By Address)
http://datawarehouse.hrsa.gov /geoHPSAAdvisor/GeographicHPSAAdvisor.aspx
Incident To Codes
For services rendered on or after January 1, 2016:
RVU16A, PPRRVU16_V0122, number “5” in column N, labeled, “PCTC IND”, (PC/TC Indicator)
For services rendered on or after April 1, 2016:
RVU16B, PPRRVU16_April_V0202, number “5” in column N, labeled, “PCTC IND”, (PC/TC Indicator)
For services rendered on or after July 1, 2016:
RVU16C, PPRRVU16_V0517, number “5” in column N, labeled, “PCTC IND”, (PC/TC Indicator)
For services rendered on or after October 1, 2016:
RVU16D, PPRRVU16_V0804, number “5” in column N, labeled, “PCTC IND”, (PC/TC Indicator)
Medi-Cal Rates - DHCS
Pursuant to section 9789.13.2, the Medi-Cal Rates file's “Basic Rate” is used in calculating maximum
fee for physician-administered drugs, biologicals, vaccines or blood products, by date of service.
For services rendered on or after January 1, 2016, use:
Medi-Cal Rates file - Updated 12/15/2015
For services rendered on or after January 15, 2016, use:
Medi-Cal Rates file - Updated 1/15/2016
For services rendered on or after February 15, 2016, use:
Medi-Cal Rates file - Updated 2/15/2016
For services rendered on or after March 15, 2016, use:
Medi-Cal Rates file - Updated 3/15/2016
For services rendered on or after April 15, 2016, use:
Medi-Cal Rates file - Updated 4/15/2016
For services rendered on or after May 15, 2016, use:
Medi-Cal Rates file - Updated 5/15/2016
For services rendered on or after June 15, 2016, use:
Medi-Cal Rates file - Updated 6/15/2016
For services rendered on or after July 15, 2016, use:
Medi-Cal Rates file - Updated 7/15/2016
For services rendered on or after August 15, 2016, use:
Medi-Cal Rates file - Updated 8/15/2016
For services rendered on or after September 15, 2016, use:
Medi-Cal Rates file - Updated 9/15/2016
For services rendered on or after October 15, 2016, use:
Medi-Cal Rates file - Updated 10/15/2016
For services rendered on or after November 15, 2016, use:
Medi-Cal Rates file - Updated 11/15/2016
For services rendered on or after December 15, 2016, use:
Medi-Cal Rates file - Updated 12/15/2016
For services rendered on or after January 15, 2017, use:
Medi-Cal Rates file - Updated 1/15/2017
For services rendered on or after February 15, 2017, use:
Medi-Cal Rates file - Updated 2/15/2017
Copies of the Medi-Cal Rates files (without CPT descriptors) are posted on the DWC website:
http://www.dir.ca.gov/dwc/OMFS9904.htm
Ophthalmology Procedure
For services rendered on or after January 1, 2016:
CPT codes subject to the
RVU16A, PPRRVU16_V0122, Number “7” in column S, labeled “Mult Proc” (Modifier 51). Also
MPPR
listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB], in the
CMS-1631-FC_Diagnostic Ophthalmology Services Subject to MPPR
For services rendered on or after April 1, 2016:
RVU16B, PPRRVU16_April_V0202, Number “7” in column S, labeled “Mult Proc” (Modifier 51). Also
listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB],
in the CMS-1631-FC_Diagnostic Ophthalmology Services Subject to MPPR
For services rendered on or after July 1, 2016:
RVU16C, PPRRVU16_V0517, Number “7” in column S, labeled “Mult Proc” (Modifier 51). Also listed in
CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB], in the
CMS-1631-FC_Diagnostic Ophthalmology Services Subject to MPPR
For services rendered on or after October 1, 2016:
RVU16D, PPRRVU16_V0804, Number “7” in column S, labeled “Mult Proc” (Modifier 51). Also listed in
CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB], in the
CMS-1631-FC_Diagnostic Ophthalmology Services Subject to MPPR
Physical Therapy Multiple
For services rendered on or after January 1, 2016:
Procedure Payment
RVU16A, PPRRVU16_V0122, Number “5” in column S, labeled “Mult Proc”. Also listed in the CY 2016
Reduction: “Always
PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB] in the document
Therapy” Codes; and
CMS-1631-FC_Separately Payable Therapy Services Subject to MPPR
Acupuncture and
Chiropractic Codes
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
For services rendered on or after April 1, 2016:
RVU16B, PPRRVU16_April_V0202, Number “5” in column S, labeled “Mult Proc”. Also listed in the
CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB] in the document
CMS-1631-FC_Separately Payable Therapy Services Subject to MPPR
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
For services rendered on or after July 1, 2016:
RVU16C, PPRRVU16_V0517, Number “5” in column S, labeled “Mult Proc”. Also listed in the CY 2016 PFS
Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB] in the document CMS-1631-FC_Separately
Payable Therapy Services Subject to MPPR
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
For services rendered on or after October 1, 2016:
RVU16D, PPRRVU16_V0804, Number “5” in column S, labeled “Mult Proc”. Also listed in the CY 2016 PFS
Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB] in the document CMS-1631-FC_Separately
Payable Therapy Services Subject to MPPR
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
Physician Time
CY 2016 PFS Final Rule Work Time [ZIP 220KB]
Statewide GAFs (Other than
Average Statewide Work GAF: 1.0420
anesthesia)
Average Statewide Practice Expense GAF: 1.1621
Average Statewide Malpractice Expense GAF: 0.7388
Statewide GAF (Anesthesia)
Average Statewide Anesthesia GAF: 1.0487
Splints and Casting Supplies
For services rendered on or after January 1, 2016, use:
The OMFS Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Fee Schedule
applicable to the date of service.
The 1995 Documentation
https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/
Guidelines for Evaluation
Downloads/95Docguidelines.pdf
& Management Services
The 1997 Documentation
https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/
Guidelines for Evaluation
Downloads/97Docguidelines.pdf
and Management Services
(d) Services Rendered On or After 3/1/2017. Documents listed in the following table are incorporated by reference and will be made available upon request to the Administrative Director.
Document/Data
Services Rendered On or After March 1, 2017 & Mid-year Updates
Adjustment Factors
For services rendered on or after March 1, 2017:
(These factors have been
incorporated into the
For all services other than anesthesia:
conversion factors listed
2017 Cumulative adjustment factor: 1.0933
below)
2017 RVU budget neutrality adjustment factor: 0.99987
2017 Imaging MPPR adjustment factor: 0.9993
2017 Annual increase in the MEI: 1.012
2016 Cumulative “other than anesthesia” adjustment: 1.0812
For anesthesia services:
2017 Cumulative anesthesia adjustment factor: 1.0433
2017 RVU budget neutrality adjustment factor: 0.99987
2017 Imaging MPPR adjustment factor: 0.9993
2017 Annual increase in the MEI: 1.012
2016 Cumulative anesthesia adjustment: 1.0317
Anesthesia Base Units by
2014anesBASEfin
CPT Code
California-Specific Codes
WC001 - Not reimbursable
WC002 - $12.29
WC003 - $39.89 for first page
$24.54 each additional page. Maximum of six pages absent mutual agreement ($162.59)
WC004 - $39.89 for first page
$24.54 each additional page. Maximum of seven pages absent mutual agreement ($187.13)
WC005 - $39.89 for first page, $24.54 each additional page. Maximum of six pages absent
mutual agreement ($162.59)
WC007 - $39.89 for first page
$24.54 each additional page. Maximum of six pages absent mutual agreement ($162.59)
WC008 - $10.58 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages.
WC009 - $10.58 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages.
WC010 - $5.29 per x-ray
WC011 - $10.58 per scan
WC012 - No Fee Prescribed /Non Reimbursable absent agreement
CCI Edits:
For services rendered on or after March 1, 2017, use:
Medically Unlikely Edits
“Practitioner Services MUE Table - Effective 1/1/2017.”
Copies of the MUE Tables are posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm
For services rendered on or after April 1, 2017, use:
“Practitioner Services MUE Table - Effective 4/1/2017.”
Copies of the MUE Tables are posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm
For services rendered on or after July 1, 2017, use:
“Practitioner Services MUE Table - Effective 7/1/2017.”
Copies of the MUE Tables are posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm
For services rendered on or after October 1, 2017, use:
“Practitioner Services MUE Table - Effective 10/1/2017.”
Copies of the MUE Tables are posted on the DWC website:
http://www.dir.ca.gov/dwc/OMFS9904.htm
CMS posts only the most recent version of the Practitioner Services MUE Table on the
web at: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html
CCI Edits:
For services rendered on or after March 1, 2017:
National Correct Coding
“NCCI Policy Manual for Medicare Services - Effective January 1, 2017 [ZIP, 770KB]”
Initiative Policy Manual for
Medicare Services
Copy of the 2017 Manual is posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm#7
CCI Edits:
For services rendered on or after March 1, 2017:
Physician CCI Edits
Practitioner PTP Edits v23.0 effective January 1, 2017 (422,052 records) 0001M/36591 - 24940/G0471
(Practitioner PTP Edits)
Practitioner PTP Edits v23.0 effective January 1, 2017 (574,135 records) 25000/01810 - 39599/49570
Practitioner PTP Edits v23.0 effective January 1, 2017 (436,857 records) 40490/00170 - 59897/G0347
Practitioner PTP Edits v23.0 effective January 1, 2017 (501,820 records) 60000/0213T - R0075/R0070
For services rendered on or after April 1, 2017:
Practitioner PTP Edits v23.1 effective April 1, 2017 (474,500 records) 0001M/36591 - 25931/G0471
Practitioner PTP Edits v23.1 effective April 1, 2017 (502,046 records) 26010/01810 - 36909/J2001
Practitioner PTP Edits v23.1 effective April 1, 2017 (495,097 records) 37140/0213T - 60650/G0471
Practitioner PTP Edits v23.1 effective April 1, 2017 (501,223 records) 61000/0213T - R0075/R0070
For services rendered on or after July 1, 2017:
Practitioner PTP Edits v23.2 effective July 1, 2017 (476,159 records) 0001M/36591 - 25931/G0471 [ZIP, 13MB]
Practitioner PTP Edits v23.2 effective July 1, 2017 (502,166 records) 26010/01810 - 36909/J2001 [ZIP, 13MB]
Practitioner PTP Edits v23.2 effective July 1, 2017 (495,291 records) 37140/0213T - 60650/G0471 [ZIP, 13MB]
Practitioner PTP Edits v23.2 effective July 1, 2017 (503,693 records) 61000/0213T - R0075/R0070 [ZIP, 13MB]
For services rendered on or after October 1, 2017:
Practitioner PTP Edits v23.3 effective October 1, 2017 (476,064 records) 0001M/36591 - 25931/G0471
Practitioner PTP Edits v23.3 effective October 1, 2017 (502,759 records) 26010/01810 - 36909/J2001
Practitioner PTP Edits v23.3 effective October 1, 2017 (495,446 records) 37140/0213T - 60650/G0471
Practitioner PTP Edits v23.3 effective October 1, 2017 (504,589 records) 61000/0213T - R0075/R0070
Access the Physician CCI Edits on the CMS website:
http://www.cms.gov/Medicare /Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html
Note: the Physician CCI Edits excel file maintained by CMS contains effective date and deletion date (if any)
for each column 1/column 2 pair. Therefore, the most recent file is the only file posted on the CMS website,
and covers all time periods.
CMS' Medicare National
For services rendered on or after March 1, 2017:
Physician Fee Schedule
RVU17A (January 2017 release) [ZIP, 3MB]
Relative Value File [Zip]
• RVU17A (Excluding Attachment A)
• PPRRVU17_V1219
• OPPSCAP_V1219
Excluding:
17LOCCO
ANES_V0101
CY2017_GPCIs
For services rendered on or after April 1, 2017:
RVU17B [ZIP, 3MB]
• RVU17B (Excluding Attachment A)
• PPRRVU17_V0209
• OPPSCAP_V0215
Excluding:
17LOCCO
ANES_V0101
CY2017_GPCIs
For services rendered on or after July 1, 2017:
RVU17C [ZIP, 3MB]
• RVU17C (Excluding Attachment A)
• PPRRVU17_JULY_V0503
• OPPSCAP_V0515
Excluding:
17LOCCO
ANES_V0101
CY2017_GPCIs
For services rendered on or after October 1, 2017:
RVU17D [ZIP, 3MB]
• RVU17D (Excluding Attachment A)
• PPRRVU17_OCT
• OPPSCAP_OCT
Excluding:
17LOCCO
ANES_OCT
CY2017_GPCIs
Conversion Factors adjusted
For services rendered on or after March 1, 2017:
for MEI and Relative
Value Scale adjustment
Anesthesia Conversion Factor: $26.8011
factor
Other Services Conversion Factor: $ 44.6572
Current Procedural
CPT 2017
Terminology (CPT(r))
https://commerce.ama-assn.org/store/
Current Procedural
Do not use CPT codes:
Terminology
27215 (Use G0412)
CPT codes that shall not
27216 (Use G0413)
be used
27217 (Use G0414)
27218 (Use G0415)
76140 (see §9789.17.2)
90889 (See §9789.14. Use code WC005)
97014 (Use G0283)
99075 (see Medical-Legal fee schedule, §9795)
99080 (see §9789.14)
99241 through 99245 (see §9789.12.12)
99251 through 99255 (see §9789.12.12)
99455 and 99456
Diagnostic Cardiovascular
For services rendered on or after March 1, 2017:
Procedure CPT codes
RVU17A, PPRRVU17_V1219, Number “6” in column S, labeled “Mult Proc” (Modifier 51), also listed in
subject to the MPPR
CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the document
CMS-1654-F_Diagnostic Cardiovascular Services Subject to MPPR
For services rendered on or after April 1, 2017:
RVU17B, PPRRVU17_V0209, Number “6” in column S, labeled “Mult Proc” (Modifier 51), also listed in
CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the document
CMS-1654-F_Diagnostic Cardiovascular Services Subject to MPPR
For services rendered on or after July 1, 2017:
RVU17C, PPRRVU17_JULY_V0503, Number “6” in column S, labeled “Mult Proc” (Modifier 51), also
listed in CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the document
CMS-1654-F_Diagnostic Cardiovascular Services Subject to MPPR
For services rendered on or after October 1, 2017:
RVU17D, PPRRVU17_OCT, Number “6” in column S,
labeled “Mult Proc” (Modifier 51), also listed in CY 2017
PFS Final Rule Multiple Procedure Payment Reduction File
[Zip, 42KB], in the document CMS-1654-F_Diagnostic
Cardiovascular Services Subject to MPPR
Diagnostic Imaging Family
For services rendered on or after March 1, 2017:
Indicator Description
Diagnostic Imaging Family Indicator:
88 = Subject to the reduction
99 = Concept does not apply
RVU17A, RVU17A (PDF document)
For services rendered on or after April 1, 2017:
Diagnostic Imaging Family Indicator:
88 = Subject to the reduction
99 = Concept does not apply
RVU17B, RVU17B (PDF document)
For services rendered on or after July 1, 2017:
Diagnostic Imaging Family Indicator:
88 = Subject to the reduction
99 = Concept does not apply
RVU17C, RVU17C (PDF document)
For services rendered on or after October 1, 2017:
Diagnostic Imaging Family Indicator:
88 = Subject to the reduction
99 = Concept does not apply
RVU17D, RVUPUF17 (PDF document)
Diagnostic Imaging Family
For services rendered on or after March 1, 2017:
Procedures Subject to the
RVU17A, PPRRVU17_V1219, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator”,
MPPR
also listed in CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the
document CMS-1654-F _Diagnostic Imaging Services Subject to MPPR
For services rendered on or after April 1, 2017:
RVU17B, PPRRVU17_V0209, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator”,
also listed in CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the
document CMS-1654-F _Diagnostic Imaging Services Subject to MPPR
For services rendered on or after July 1, 2017:
RVU17C, PPRRVU17_JULY_V0503, number “88” in column AB, labeled, “Diagnostic Imaging Family
Indicator”, also listed in CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in
the document CMS-1654-F _Diagnostic Imaging Services Subject to MPPR
For services rendered on or after October 1, 2017:
RVU17D, PPRRVU17_OCT, number “88” in column AB, labeled,
“Diagnostic Imaging Family Indicator,” also listed in
CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB],
in the document CMS-1654-F _Diagnostic Imaging Services Subject to MPPR
Diagnostic Imaging
For services rendered on or after March 1, 2017:
Multiple Procedures
RVU17A, PPRRVU17_V1219, number “4” in column S, labeled, “Mult Proc”, also listed in CY 2017 PFS
Subject to the MPPR
Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the document
CMS-1654-F_Diagnostic Imaging Services Subject to MPPR
For services rendered on or after April 1, 2017:
RVU17B, PPRRVU17_V0209, number “4” in column S, labeled, “Mult Proc”, also listed in CY 2017 PFS
Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the document
CMS-1654-F_Diagnostic Imaging Services Subject to MPPR
For services rendered on or after July 1, 2017:
RVU17C, PPRRVU17_JULY_V0503, number “4” in column S, labeled, “Mult Proc”, also listed in
CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the document
CMS-1654-F_Diagnostic Imaging Services Subject to MPPR
For services rendered on or after October 1, 2017:
RVU17D, PPRRVU17_OCT, number “4” in column S,
labeled, “Mult Proc,” also listed in CY 2017 PFS Final Rule
Multiple Procedure Payment Reduction File [Zip, 42KB], in
the document CMS-1654-F_Diagnostic Imaging Services Subject to MPPR
DWC Pharmaceutical
http://www.dir.ca.gov/dwc/OMFS9904.htm#8
Fee Schedule
Geographic Health
2017 Primary Care HPSA [ZIP, 99KB]
Professional Shortage Area
2017 Mental Health HPSA [ZIP, 237KB]
zip code data files
Access the files on the CMS website: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/
HPSAPSAPhysicianBonuses/ index.html?redirect=/hpsapsaphysicianbonuses/
Health Resources and
Services Administration:
Geographic HPSA shortage
area query
(By State & County)
http://hpsafind.hrsa.gov/
(By Address)
http://datawarehouse.hrsa.gov/ geoHPSAAdvisor/GeographicHPSAAdvisor.aspx
Incident To Codes
For services rendered on or after March 1, 2017:
RVU17A, PPRRVU17_V1219, number “5” in column N, labeled, “PCTC IND”, (PC/TC Indicator)
For services rendered on or after April 1, 2017:
RVU17B, PPRRVU17_V0209, number “5” in column N, labeled, “PCTC IND”, (PC/TC Indicator)
For services rendered on or after July 1, 2017:
RVU17C, PPRRVU17_JULY_V0503, number “5” in column N, labeled, “PCTC IND”, (PC/TC Indicator)
For services rendered on or after October 1, 2017:
RVU17D, PPRRVU17_OCT, number “5” in column N,
labeled, “PCTC IND,” (PC/TC Indicator)
Medi-Cal Rates - DHCS
Pursuant to section 9789.13.2, the Medi-Cal Rates file's “Basic Rate” is used in calculating maximum fee
for physician-administered drugs, biologicals, vaccines or blood products, by date of service.
For services rendered on or after March 1, 2017 use:
Medi-Cal Rates file - Updated 2/15/2017
For services rendered on or after March 15, 2017, use:
Medi-Cal Rates file - Updated 3/15/2017
For services rendered on or after April 15, 2017, use:
Medi-Cal Rates file - Updated 4/15/2017
For services rendered on or after May 15, 2017, use:
Medi-Cal Rates file - Updated 5/15/2017
For services rendered on or after June 15, 2017, use:
Medi-Cal Rates file - Updated 6/15/2017
For services rendered on or after July 15, 2017, use:
Medi-Cal Rates file - Updated 7/15/2017
For services rendered on or after August 15, 2017, use:
Medi-Cal Rates file - Updated 8/15/2017
For services rendered on or after September 15, 2017, use:
Medi-Cal Rates file - Updated 9/15/2017
For services rendered on or after October 15, 2017, use:
Medi-Cal Rates file - Updated 10/15/2017
For services rendered on or after November 15, 2017, use:
Medi-Cal Rates file - Updated 11/15/2017
For services rendered on or after December 15, 2017, use:
Medi-Cal Rates file - Updated 12/15/2017
Copies of the Medi-Cal Rates files (without CPT descriptors) are posted on the DWC
website: http://www.dir.ca.gov/dwc/OMFS9904.htm
Ophthalmology Procedure
For services rendered on or after March 1, 2017:
CPT codes subject to the
RVU17A, PPRRVU17_V1219, Number “7” in column S, labeled “Mult Proc” (Modifier 51). Also listed in
MPPR
CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the
CMS-1654-F_Diagnostic Ophthalmology Services Subject to MPPR
For services rendered on or after April 1, 2017:
RVU17B, PPRRVU17_V0209, Number “7” in column S, labeled “Mult Proc” (Modifier 51). Also listed in
CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the
CMS-1654-F_Diagnostic Ophthalmology Services Subject to MPPR
For services rendered on or after July 1, 2017:
RVU17C, PPRRVU17_JULY_V0503, Number “7” in column S, labeled “Mult Proc” (Modifier 51). Also
listed in CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the
CMS-1654-F_Diagnostic Ophthalmology Services Subject to MPPR
For services rendered on or after October 1, 2017:
RVU17D, PPRRVU17_OCT, Number “7” in column S,
labeled “Mult Proc” (Modifier 51). Also listed in CY 2017 PFS
Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB],
in the CMS-1654-F_Diagnostic Ophthalmology Services Subject to MPPR
Physical Therapy Multiple
For services rendered on or after March 1, 2017:
Procedure Payment
RVU17A, PPRRVU17_V1219, Number “5” in column S, labeled “Mult Proc”. Also listed in the CY 2017
Reduction: “Always
PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB] in the document
Therapy” Codes; and
CMS-1654-F_Separately Payable Therapy Services Subject to MPPR
Acupuncture and
Chiropractic Codes
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
For services rendered on or after April 1, 2017:
RVU17B, PPRRVU17_V0209, Number “5” in column S, labeled “Mult Proc”. Also listed in the CY 2017
PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB] in the document
CMS-1654-F_Separately Payable Therapy Services Subject to MPPR
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
For services rendered on or after July 1, 2017:
RVU17C, PPRRVU17_JULY_V0503, Number “5” in column S, labeled “Mult Proc”. Also listed in the
CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB] in the
document CMS-1654-F_Separately Payable Therapy Services Subject to MPPR
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
For services rendered on or after October 1, 2017:
RVU17D, PPRRVU17_OCT, Number “5” in column S, labeled “Mult Proc.”
Also listed in the CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File
[Zip, 42KB] in the document CMS-1654-F_Separately Payable Therapy Services Subject to MPPR
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
Physician Time
CY 2017 PFS Final Rule Physician Time [ZIP, 628KB]
Statewide GAFs (Other
Average Statewide Work GAF: 1.0417
than anesthesia)
Average Statewide Practice Expense GAF: 1.1632
Average Statewide Malpractice Expense GAF: 0.6632
Statewide GAF
Average Statewide Anesthesia GAF: 1.0374
(Anesthesia)
Splints and Casting
For services rendered on or after March 1, 2017, use:
Supplies
The OMFS Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Fee Schedule
applicable to the date of service.
The 1995 Documentation
https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/
Guidelines for Evaluation
Downloads/95Docguidelines.pdf
& Management Services
The 1997 Documentation
https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/
Guidelines for Evaluation
Downloads/97Docguidelines.pdf
and Management Services
(e) Services Rendered On or After 1/1/2018. Documents listed in the following table are incorporated by reference and will be made available upon request to the Administrative Director.
Document/Data
Services Rendered On or After January 1, 2018 & Mid-year Updates
Adjustment Factors
For services rendered on or after January 1, 2018:
(These factors have been
incorporated into the
For all services other than anesthesia:
conversion factors
2018 Cumulative adjustment factor: 1.1075
listed below)
2018 RVU budget neutrality adjustment factor: 0.9990
2018 Annual increase in the MEI: 1.014
2017 Cumulative “other than anesthesia” adjustment: 1.0933
For anesthesia services:
2018 Cumulative anesthesia adjustment factor: 1.0604
2018 RVU budget neutrality adjustment factor: 0.9990
2018 Annual increase in the MEI: 1.014
2018 Anesthesia practice expense and malpractice adjustment factor: 1.0034
2017 Cumulative anesthesia adjustment: 1.0433
Anesthesia Base Units by
cms1676f_cy_2018_anesthesia_base_units.xlsx
CPT Code
California-Specific Codes
WC001 - Not reimbursable
WC002 - $12.46
WC003 - $40.45 for first page
$24.88 each additional page. Maximum of six pages absent mutual agreement ($164.85)
WC004 - $40.45 for first page
$24.88 each additional page. Maximum of seven pages absent mutual agreement ($189.73)
WC005 - $40.45 for first page, $24.88 each additional page. Maximum of six pages absent
mutual agreement ($164.85)
WC007 - $40.45 for first page
$24.88 each additional page. Maximum of six pages absent mutual agreement ($164.85)
WC008 - $10.73 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages.
WC009 - $10.73 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages.
WC010 - $5.36 per x-ray
WC011 - $10.73 per scan
WC012 - No Fee Prescribed/Non Reimbursable absent agreement
CCI Edits:
For services rendered on or after January 1, 2018, use:
Medically Unlikely Edits
“Practitioner Services MUE Table - Effective 1/1/18.”
Copy of the MUE Table is posted on the DWC website:
http://www.dir.ca.gov/dwc/OMFS9904.htm
For services rendered on or after April 1, 2018, use:
“Practitioner Services MUE Table - Effective 4/1/18.”
Copy of the MUE Table is posted on the DWC website:
http://www.dir.ca.gov/dwc/OMFS9904.htm
For services rendered on or after July 1, 2018, use:
“Practitioner Services MUE Table - Effective 07-01-2018 [ZIP, 346KB],” excluding all codes listed with
Practitioner Services MUE Value of “0” (zero).
Excerpts of the MUE Table is posted on the DWC website:
http://www.dir.ca.gov/dwc/OMFS9904.htm
For services rendered on or after October 1, 2018, use:
“Practitioner Services MUE Table - Effective 10-01-2018 [ZIP, 346KB],” excluding all codes listed with
Practitioner Services MUE Value of “0” (zero).
Excerpts of the MUE Table is posted on the DWC website:
http://www.dir.ca.gov/dwc/OMFS9904.htm
CCI Edits:
For services rendered on or after January 1, 2018:
National Correct Coding
“NCCI Policy Manual for Medicare Services - Effective January 1, 2018 [ZIP, 851KB]”
Initiative Policy Manual for
Medicare Services
Copy of the 2018 Manual is posted on the DWC website:
http://www.dir.ca.gov/dwc/OMFS9904.htm#7
CCI Edits:
For services rendered on or after January 1, 2018:
Practitioner Procedure to
Procedure (PTP) Edits
Practitioner PTP Edits v24.0 effective January 1, 2018 (511,599 records) 0001M/36591 - 25931/G0471
Practitioner PTP Edits v24.0 effective January 1, 2018 (507,927 records) 26010/01810 - 36909/J2001
Practitioner PTP Edits v24.0 effective January 1, 2018 (474,903 records) 37140/0213T - 60650/G0471
Practitioner PTP Edits v24.0 effective January 1, 2018 (514,837 records) 61000/0213T - R0075/R0070
For services rendered on or after April 1, 2018:
Practitioner PTP Edits v24.1 effective April 1, 2018 (537,183 records) 0001M/36591 - 25931/G0471
Practitioner PTP Edits v24.1 effective April 1, 2018 (482,358 records) 26010/01810 - 36909/J2001
Practitioner PTP Edits v24.1 effective April 1, 2018 (523,111 records) 37140/0213T - 60650/G0471
Services Rendered On or After January 1, 2018 & Mid-year Updates
Practitioner PTP Edits v24.1 effective April 1, 2018 (466,820 records) 61000/0213T - R0075/R0070
For services rendered on or after July 1, 2018:
Practitioner PTP Edits v24.2 effective July 1, 2018 (539,120 records) 0001M/36591 - 26992/G0471
Practitioner PTP Edits v24.2 effective July 1, 2018 (482,378 records) 27000/01995 - 37790/G0471
Practitioner PTP Edits v24.2 effective July 1, 2018 (523,129 records) 38100/0213T - 61888/G0471
Practitioner PTP Edits v24.2 effective July 1, 2018 (467,725 records) 62000/0213T - R0075/R0070
For services rendered on or after October 1, 2018:
Practitioner PTP Edits v24.3 effective October 1, 2018 (539,717 records) 0001M/36591 - 26992/G0471
Practitioner PTP Edits v24.3 effective October 1, 2018 (482,493 records) 27000/01995 - 37790/G0471
Practitioner PTP Edits v24.3 effective October 1, 2018 (523,504 records) 38100/0213T - 61888/G0471
Practitioner PTP Edits v24.3 effective October 1, 2018 (467,777 records) 62000/0213T - R0075/R0070
Access the Practitioner PTP Edits on the CMS website:
http://www.cms.gov/Medicare/ Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html
Note: the Practitioner PTP Edits excel file maintained by CMS contains effective date and deletion date (if any) for each column 1/column 2 pair. Therefore, the most recent file is the only file posted on the CMS website, and covers all time periods.
CMS' Medicare National
For services rendered on or after January 1, 2018:
Physician Fee Schedule
RVU18A (Updated 12/20/2017) [ZIP, 3MB]
Relative Value File [Zip]
• RVU18A (excluding Attachment A)
• PPRRVU18 JAN
• OPPSCAP_JAN
Excluding:
18LOCCO
ANES2018
GPCI2018
For services rendered on or after April 1, 2018:
RVU18B [ZIP, 3MB]
• RVU18B (excluding Attachment A)
• PPRRVU18 APR
• OPPSCAP_APR
Excluding:
18LOCCO
ANES2018
GPCI2018
For services rendered on or after July 1, 2018:
RVU18C1 [ZIP, 3MB]
• RVU18C (excluding Attachment A)
• PPRRVU18 JUL
• OPPSCAP_JUL
Excluding:
18LOCCO
ANES2018
GPCI2018
For services rendered on or after October 1, 2018:
RVU18D [ZIP, 3MB]
• RVU18D (excluding Attachment A)
• PPRRVU18 OCT
• OPPSCAP_OCT
Excluding:
18LOCCO
ANES2018
GPCI2018
Conversion Factors adjusted
For services rendered on or after January 1, 2018:
for MEI and Relative Value
Scale adjustment factor
Anesthesia Conversion Factor: $27.2415
Other Services Conversion Factor: $45.2371
Current Procedural
CPT 2018
Terminology (CPT®)
https://commerce.ama-assn.org/store/
Current Procedural
Do not use CPT codes:
Terminology
27215 (Use G0412)
CPT codes that shall not
27216 (Use G0413)
be used
27217 (Use G0414)
27218 (Use G0415)
76140 (see §9789.17.2)
90889 (See §9789.14. Use codeWC005 code)
97014 (Use G0283)
97127 (Use G0515)
99075 (see Medical-Legal fee schedule, §9795)
99080 (see §9789.14)
99241 through 99245 (see §9789.12.12)
99251 through 99255 (see §9789.12.12)
99455 and 99456
Diagnostic Cardiovascular
For services rendered on or after January 1, 2018:
Procedure CPT codes
RVU18A, PPRRVU18_JAN, number “6” in column S,
subject to the MPPR
labeled “Mult Proc” (Modifier 51), also listed in CY 2018
PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB],
in the document CMS-1676-F_Diagnostic Cardiovascular Services Subject to MPPR
For services rendered on or after April 1, 2018:
RVU18B, PPRRVU18_APR, number “6” in column S, labeled “Mult Proc” (Modifier 51),
also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB],
in the document CMS-1676-F_Diagnostic Cardiovascular Services Subject to MPPR
For services rendered on or after July 1, 2018:
RVU18C1, PPRRVU18_JUL, number “6” in column S, labeled “Mult Proc” (Modifier 51),
also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB],
in the document CMS-1676-F_Diagnostic Cardiovascular Services Subject to MPPR
For services rendered on or after October 1, 2018:
RVU18D, PPRRVU18_OCT, number “6” in column S, labeled “Mult Proc” (Modifier 51),
also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB],
in the document CMS-1676-F_Diagnostic Cardiovascular Services Subject to MPPR
Diagnostic Imaging Family
For services rendered on or after January 1, 2018:
Indicator Description
Diagnostic Imaging Family Indicator:
88 = Subject to the reduction
99 = Concept does not apply
RVU18A, RVU18A (PDF document)
For services rendered on or after April 1, 2018:
Diagnostic Imaging Family Indicator:
88 = Subject to the reduction
99 = Concept does not apply
RVU18B, RVU18B (PDF document)
For services rendered on or after July 1, 2018:
Diagnostic Imaging Family Indicator:
88 = Subject to the reduction
99 = Concept does not apply
RVU18C1, RVU18C (PDF document)
For services rendered on or after October 1, 2018:
Diagnostic Imaging Family Indicator:
88 = Subject to the reduction
99 = Concept does not apply
RVU18D, RVU18D (PDF document)
Diagnostic Imaging Family
For services rendered on or after January 1, 2018:
Procedures Subject to the
RVU18A, PPRRVU18_JAN, number “88” in column AB,
MPPR
labeled, “Diagnostic Imaging Family Indicator,” also listed in CY 2018
PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document
CMS-1676-F_Diagnostic Imaging Services Subject to MPPR
For services rendered on or after April 1, 2018:
RVU18B, PPRRVU18_APR, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator,”
also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document
CMS-1676-F_Diagnostic Imaging Services Subject to MPPR
For services rendered on or after July 1, 2018:
RVU18C1, PPRRVU18_JUL, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator,”
also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document
CMS-1676-F_Diagnostic Imaging Services Subject to MPPR
For services rendered on or after October 1, 2018:
RVU18D, PPRRVU18_OCT, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator,”
also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document
CMS-1676-F_Diagnostic Imaging Services Subject to MPPR
Diagnostic Imaging
For services rendered on or after January 1, 2018:
Multiple Procedures
RVU18A, PPRRVU18_JAN, number “4” in column S, labeled, “Mult Proc,” also listed in
Subject to the MPPR
CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB],
in the document CMS-1676-F_Diagnostic Imaging Services Subject to MPPR
For services rendered on or after April 1, 2018:
RVU18B, PPRRVU18_APR, number “4” in column S, labeled, “Mult Proc,” also listed in CY 2018 PFS Final
Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Imaging
Services Subject to MPPR
For services rendered on or after July 1, 2018:
RVU18C1, PPRRVU18_JUL, number “4” in column S, labeled, “Mult Proc,” also listed in CY 2018 PFS Final
Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Imaging
Services Subject to MPPR
For services rendered on or after October 1, 2018:
RVU18D, PPRRVU18_OCT, number “4” in column S, labeled, “Mult Proc,” also listed in CY 2018 PFS Final
Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Imaging
Services Subject to MPPR
DWC Pharmaceutical
http://www.dir.ca.gov/dwc/OMFS9904.htm#8
Fee Schedule
Geographic Health
2018 Primary Care HPSA [ZIP, 98KB]
Professional
2018 Mental Health HPSA [ZIP, 218KB]
Shortage Area zip code
Access the files on the CMS website:
data files
https://www.cms.gov/Medicare/Medicare-Fee-for- Service-Payment/HPSAPSAPhysicianBonuses/
index.html?redirect=/hpsapsaphysicianbonuses/
Health Resources and
Services Administration:
Geographic HPSA shortage
area query
(By State & County)
http://hpsafind.hrsa.gov/
(By Address)
http://datawarehouse.hrsa.gov/ geoHPSAAdvisor/GeographicHPSAAdvisor.aspx
Incident To Codes
For services rendered on or after January 1, 2018:
RVU18A, PPRRVU18_JAN, number “5” in column N, labeled, “PCTC IND,” (PC/TC Indicator)
For services rendered on or after April 1, 2018:
RVU18B, PPRRVU18_APR, number “5” in column N, labeled, “PCTC IND,” (PC/TC Indicator)
For services rendered on or after July 1, 2018:
RVU18C1, PPRRVU18_JUL, number “5” in column N, labeled, “PCTC IND,” (PC/TC Indicator)
For services rendered on or after October 1, 2018:
RVU18D, PPRRVU18_OCT, number “5” in column N, labeled, “PCTC IND,” (PC/TC Indicator)
Medi-Cal Rates - DHCS
fee for physician-administered drugs, biologicals, vaccines or blood products, by date of service.
For services rendered on or after January 1, 2018, use:
Medi-Cal Rates file - Updated 12/15/2017
For services rendered on or after January 15, 2018, use:
Medi-Cal Rates file - Updated 1/15/2018
For services rendered on or after February 15, 2018, use:
Medi-Cal Rates file - Updated 2/15/2018
For services rendered on or after March 15, 2018, use:
Medi-Cal Rates file - Updated 3/15/2018
For services rendered on or after April 15, 2018, use:
Medi-Cal Rates file - Updated 4/15/2018
For services rendered on or after May 15, 2018, use:
Medi-Cal Rates file - Updated 5/15/2018
For services rendered on or after June 15, 2018, use:
Medi-Cal Rates file - Updated 6/15/2018
For services rendered on or after July 15, 2018, use:
Medi-Cal Rates file - Updated 7/15/2018
For services rendered on or after August 15, 2018, use:
Medi-Cal Rates file - Updated 8/15/2018
For services rendered on or after September 15, 2018, use:
Medi-Cal Rates file - Updated 9/15/2018
For services rendered on or after October 15, 2018, use:
Medi-Cal Rates file - Updated 10/15/2018
For services rendered on or after November 15, 2018, use:
Medi-Cal Rates file - Updated 11/15/2018
For services rendered on or after December 15, 2018, use:
Medi-Cal Rates file - Updated 12/15/2018
Copies of the Medi-Cal Rates files (without CPT descriptors) are posted on the DWC website:
http://www.dir.ca.gov/dwc/OMFS9904.htm
Ophthalmology Procedure
For services rendered on or after January 1, 2018:
CPT codes subject to
RVU18A, PPRRVU18_JAN, number “7” in column S, labeled “Mult Proc” (Modifier 51).
the MPPR
Also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in
the document CMS-1676-F_Diagnostic Ophthalmology Services Subject to MPPR
For services rendered on or after April 1, 2018:
RVU18B, PPRRVU18_APR, number “7” in column S, labeled “Mult Proc” (Modifier 51).
Also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB],
in the document CMS-1676-F_Diagnostic Ophthalmology Services Subject to MPPR
For services rendered on or after July 1, 2018:
RVU18C1, PPRRVU18_JUL, number “7” in column S, labeled “Mult Proc” (Modifier 51).
Also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB],
in the document CMS-1676-F_Diagnostic Ophthalmology Services Subject to MPPR
For services rendered on or after October 1, 2018:
RVU18D, PPRRVU18_OCT, number “7” in column S, labeled “Mult Proc” (Modifier 51).
Also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB],
in the document CMS-1676-F_Diagnostic Ophthalmology Services Subject to MPPR
Physical Therapy Multiple
For services rendered on or after January 1, 2018:
Procedure Payment
RVU18A, PPRRVU18_JAN, number “5” in column S, labeled “Mult Proc.”
Reduction: “Always
Also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB],
Therapy” Codes; and
in the document CMS-1676-F_Separately Payable Therapy Services Subject to MPPR
Acupuncture and
Chiropractic Codes
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
For services rendered on or after April 1, 2018:
RVU18B, PPRRVU18_APR, number “5” in column S, labeled “Mult Proc.”
Also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB],
in the document CMS-1676-F_Separately Payable Therapy Services Subject to MPPR
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
For services rendered on or after July 1, 2018:
RVU18C1, PPRRVU18_JUL, number “5” in column S, labeled “Mult Proc.”
Also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB],
in the document CMS-1676-F_Separately Payable Therapy Services Subject to MPPR
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
For services rendered on or after October 1, 2018:
RVU18D, PPRRVU18_OCT, number “5” in column S, labeled “Mult Proc.”
Also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB],
in the document CMS-1676-F_Separately Payable Therapy Services Subject to MPPR
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943
Physician Time
CY 2018 PFS Final Rule Physician Time [ZIP, 591KB]
Statewide GAFs (Other
Average Statewide Work GAF: 1.041
than anesthesia)
Average Statewide Practice Expense GAF: 1.166
Average Statewide Malpractice Expense GAF: 0.605
Statewide GAF (Anesthesia)
Average Statewide Anesthesia GAF: 1.034
Splints and Casting Supplies
For services rendered on or after January 1, 2018, use:
The OMFS Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS)
Fee Schedule applicable to the date of service.
The 1995 Documentation
https://www.cms.gov/ Outreach-and-Education/Medicare-Learning-Network-MLN/
Guidelines for Evaluation
MLNEdWebGuide/Downloads/ 95Docguidelines.pdf
& Management Services
The 1997 Documentation
https://www.cms.gov/ Outreach-and-Education/Medicare-Learning-Network-MLN/
Guidelines for Evaluation
MLNEdWebGuide/Downloads/ 97Docguidelines.pdf
& Management Services
(f) Services Rendered On or After January 1, 2019. Documents listed in the following table are incorporated by reference and will be made available upon request to the Administrative Director.
Document/Data
Services Rendered On or After January 1, 2019 & Mid-year Updates
Adjustment Factors
For all services other than anesthesia:
(These factors have been
2019 Cumulative adjustment factor: 1.1226
incorporated into the
2019 RVU budget neutrality adjustment factor: 0.9986
conversion factors listed
2019 Annual increase in the MEI: 1.015
below)
2018 Cumulative “other than anesthesia” adjustment: 1.1075
For anesthesia services:
2019 Cumulative anesthesia adjustment factor: 1.0777
2019 RVU budget neutrality adjustment factor: 0.9986
2019 Annual increase in the MEI: 1.015
2019 Anesthesia practice expense and malpractice adjustment factor: 1.0027
2018 Cumulative anesthesia adjustment: 1.0604
Anesthesia Base Units by
cms1676f_cy_2018_anesthesia_base_units.xlsx
CPT Code
California-Specific Codes
WC001 - Not reimbursable
WC002 - $12.65
WC003 - $41.06 for first page
$25.25 each additional page. Maximum of six pages absent mutual agreement ($167.31)
WC004 - $41.06 for first page
$25.25 each additional page. Maximum of seven pages absent mutual agreement ($192.56)
WC005 - $41.06 for first page, $25.25 each additional page. Maximum of six pages absent mutual
agreement ($167.31)
WC007 - $41.06 for first page
$25.25 each additional page. Maximum of six pages absent mutual agreement ($167.31)
WC008 - $10.89 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages.
WC009 - $10.89 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages.
WC010 - $5.44 per x-ray
WC011 - $10.89 per scan
WC012 - No Fee Prescribed/Non Reimbursable absent agreement
CCI Edits:
Medically Unlikely Edits
For services rendered on or after January 1, 2019, use:
“Practitioner Services MUE Table - Effective 01/01/2019,”
[ZIP, 350KB]” excluding all codes listed with Practitioner Services
MUE Value of “0” (zero).
Excerpts of the MUE Tables are posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm
CCI Edits:
“NCCI Policy Manual for Medicare Services - Effective January 1, 2019 [ZIP, 1MB]”
National Correct Coding
Initiative Policy Manual
Copy of the 2019 Manual is posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm#7
for Medicare Services
CCI Edits:
For services rendered on or after January 1, 2019:
Practitioner Procedure to
Procedure (PTP) Edits
Practitioner PTP Edits v25.0 effective January 1, 2019 (556,965 records) 0001M/36591-26992/G0471
Practitioner PTP Edits v25.0 effective January 1, 2019 (489,643 records) 27000/01995-37790/G0471
Practitioner PTP Edits V25.0 effective January 1, 2019 (529,244 records) 38100/0213T-61888/G0471
Practitioner PTP Edits v25.0 effective January 1, 2019 (483,364 records) 62000/0213T-R0075/R0070
Access the Practitioner PTP Edits on the CMS website:
http://www.cms.gov/Medicare/ Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html
Note: the Practitioner PTP Edits excel file maintained by CMS contains effective date and deletion date
(if any) for each column 1/column 2 pair. Therefore, the most recent file is the only file posted on the CMS
website, and covers all time periods.
CMS' Medicare National
For services rendered on or after January 1, 2019:
Physician Fee Schedule
RVU19A [ZIP, XMB]
Relative Value File [Zip]
• RVU19A-508 (Excluding Attachment A)
• PPRRVU19 Jan
• OPPSCAP_Jan
• 19LOCCO
• GPCI2019
Excluding:
ANES2019
Access the Relative Value File on the CMS website:
https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-
Value-Files.html
Conversion Factors
Anesthesia Conversion Factor: $27.6859
adjusted for MEI and
Relative Value Scale
Other Services Conversion Factor: $45.8513
adjustment factor
Current Procedural
CPT 2019
Terminology (CPT®)
https://commerce.ama-assn.org/store/
Current Procedural
Do not use CPT codes:
Terminology
27215 (Use G0412)
CPT codes that shall
27216 (Use G0413)
not be used
27217 (Use G0414)
27218 (Use G0415)
76140 (see §9789.17.2)
90889 (See §9789.14. Use codeWC005 code)
97014 (Use G0283)
97127 (Use G0515)
99075 (see Medical-Legal fee schedule, §9795)
99080 (see §9789.14)
99241 through 99245 (see §9789.12.12)
99251 through 99255 (see §9789.12.12)
99455 and 99456
Diagnostic Cardiovascular
For services rendered on or after January 1, 2019:
Procedure CPT codes
RVU19A, PPRRVU19_Jan, number “6” in column S, labeled “Mult Proc” (Modifier 51),
subject to the MPPR
also listed in CY 2019 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 61KB],
in the document CMS-1693-F_Diagnostic Cardiovascular Services Subject to MPPR
Diagnostic Imaging
For services rendered on or after January 1, 2019:
Family Indicator
Diagnostic Imaging Family Indicator:
Description
88 = Subject to the reduction
99 = Concept does not apply
RVU19A, RVU19A-508 (PDF document)
Diagnostic Imaging
For services rendered on or after January 1, 2019:
Family Procedures
RVU19A, PPRRVU19_Jan, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator,”
Subject to the MPPR
also listed in CY 2019 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 61KB],
in the document CMS-1693-F_Diagnostic Imaging Services Subject to MPPR
Diagnostic Imaging
For services rendered on or after January 1, 2019:
Multiple Procedures
RVU19A, PPRRVU19_Jan, number “4” in column S, labeled, “Mult Proc,”
Subject to the MPPR
also listed in CY 2019 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 61KB],
in the document CMS-1693-F_Diagnostic Imaging Services Subject to MPPR
DWC Pharmaceutical
http://www.dir.ca.gov/dwc/OMFS9904.htm#8
Fee Schedule
Geographic Practice Cost
For services rendered on or after January 1, 2019:
Index (GPCI) by locality
RVU19A
(Other than anesthesia
• GPCI9019 Addendum E - Column B (“Locality Number”), Column C (“Locality Name”),
services)
column D (“2019 PW GPCI”), column E (“PE GPCI”), and column F (“MP GPCI”) for the State of California (“CA”)
• 19LOCCO - Column B (“Locality Number”), column C (“State”), column D (“Fee Schedule Area”)
and column E (“Counties”) for the State of California (“CA”)
Access the Relative Value File on the CMS website:
https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-
Value-Files.html
Also, see Zip Code mapping files listed below.
Geographic Practice Cost
For services rendered on or after January 1, 2019:
Index (GPCIs) by locality
and anesthesia shares
2019 Anesthesia Conversion Factors [ZIP, 18KB] (These factors have been incorporated into the conversion
(Anesthesia)
factors listed on section 9789.19.1, Table A)
• Locality-Adjusted Anesthesia Conversion Factors as a result of the CY 2019 Final Rule, excluding column G
labeled, “National Anes CF of 22.2730”
• Anesthesia Shares
RVU19A (County to locality index)
• 19LOCCO - Column B (“Locality Number”), column C (“State”), column D (“Fee Schedule Area”)
and column E (“Counties”) for the State of California (“CA”)
Access the Anesthesia Conversion Factors File on the CMS website:
https://www.cms.gov/Center/ Provider-Type/Anesthesiologists-Center.html
Access the Relative Value File on the CMS website:
https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-
Value-Files.html
Also, see Zip Code mapping files listed below.
Geographic Practice Cost
For services rendered on or after January 1, 2019:
Index (GPCI) locality
mapping
Zip Code to Carrier Locality File - Revised 11/14/2018 [ZIP, 4MB], Column A (“STATE”), column B (“ZIP CODE”),
and column D (“LOCALITY”) for the State of California (“CA”)
Zip Code files mapping
Zip Codes requiring + 4 extension - Revised 11/14/2018 [ZIP, 1KB], for the State of California (“CA”)
zip codes to GPCI
locality (for “other than
The Zip Code files can be accessed on the CMS website:
anesthesia services” and
https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/index.html
anesthesia services)
Geographic Health
2019 Primary Care HPSA [ZIP, 100KB]
Professional Shortage
2019 Mental Health HPSA [ZIP, 218KB]
Area zip code data files
Access the files on the CMS website:
https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses/
index.html?redirect=/hpsapsaphysicianbonuses/
Health Resources and
Services Administration:
Geographic HPSA shortage
area query
(By State & County)
http://hpsafind.hrsa.gov/
(By Address)
http://datawarehouse.hrsa.gov/ geoHPSAAdvisor/GeographicHPSAAdvisor.aspx
Incident To Codes
For services rendered on or after January 1, 2019:
RVU19A, PPRRVU19_Jan, number “5” in column N, labeled, “PCTC IND,” (PC/TC Indicator)
Medi-Cal Rates - DHCS
Pursuant to section 9789.13.2, the Medi-Cal Rates file's “Basic Rate” is used in calculating maximum fee
for physician-administered drugs, biologicals, vaccines or blood products, by date of service.
For services rendered on or after January 1, 2019, use:
Medi-Cal Rates file - Updated 12/15/2018
Copies of the Medi-Cal Rates files (without CPT descriptors) are posted on the DWC website:
http://www.dir.ca.gov/dwc/OMFS9904.htm
Ophthalmology Procedure
For services rendered on or after January 1, 2019:
CPT codes subject to
RVU19A, PPRRVU19_Jan, number “7” in column S, labeled “Mult Proc” (Modifier 51).
the MPPR
Also listed in CY 2019 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 61KB],
in the document CMS-1693-F_Diagnostic Ophthalmology Services Subject to MPPR
Physical Therapy Multiple
For services rendered on or after January 1, 2019:
Procedure Payment
RVU19A, PPRRVU19_Jan, number “5” in column S, labeled “Mult Proc.”
Reduction: “Always
Also listed in CY 2019 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 61KB],
Therapy” Codes; and
in the document CMS-1693-F_Separately Payable Therapy Services Subject to MPPR
Chiropractic Codes
In addition, CPT codes: 98940, 98941, 98942, 98943
Physician Time
CY 2019 PFS Final Rule Physician Time [ZIP, 244KB]
Splints and Casting
The OMFS Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Fee Schedule applicable
Supplies
to the date of service.
The 1995 Documentation
https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/
Guidelines for Evaluation
Downloads/95Docguidelines.pdf
& Management Services
The 1997 Documentation
https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/
Guidelines for Evaluation
Downloads/97Docguidelines.pdf
& Management Services
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 of table 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).
3. Editorial correction of Table (Register 2015, No. 16).
4. Amendment of subsection (a) and new subsections (b) and (c) filed 3-23-2016; operative 1-1-2016 pursuant to Labor Code section 5307.1(g)(2). Submitted to OAL for filing and printing only pursuant to Labor Code section 5307.1(g)(2) (Register 2016, No. 13).
5. Editorial correction (Register 2017, No. 5).
6. Amendment of subsection (c) and new subsection (d) filed 7-18-2017; operative 3-1-2017. Submitted to OAL as a file and print only pursuant to Labor Code section 5307.1(g)(2) (Register 2017, No. 29).
7. Editorial correction of subsection (c) table headings (Register 2017, No. 30).
8. Amendment of subsection (d) and new subsection (e) filed 12-28-2017; operative 1-1-2018. Submitted to OAL for filing and printing only pursuant to Labor Code section 5307-1(g)(2) (Register 2017, No. 52).
9. Amendment filed 11-6-2018; operative 1-1-2019. Submitted to OAL for filing and printing only pursuant to Government Code section 11340.9(g) (Register 2018, No. 45).
10. Editorial correction of subsection (e) (Register 2018, No. 52).
11. Amendment of subsections (e) and (f) filed 12-26-2018; operative 1-1-2019. Submitted to OAL for filing and printing only pursuant to Labor Code section 5307.1(g)(2) (Register 2018, No. 52).


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