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

§9789.16.4. Surgery - Global Fee; Exception: Circumstances Allowing E&M Code During the Global Period; Primary Treating Physician's Progress Report (PR-2).

(a) Notwithstanding sections 9789.16.2 - 9789.16.3, where a surgical code is subject to a global period, the provider may separately bill an E&M service during the global period in the following circumstance.

The provider may bill one or more evaluation and management codes for medically necessary services that exceed the number of visits that are listed for the global surgical code in the Medicare Physician Fee Schedule's “Physician Time File”. See section 9789.19 for the Physician Time File, by date of service.

Calculation shall be made as follows: For the surgical procedure subject to the global days, add the number of visits for all E&M services shown on that row in the Physician Time File. Round up if the total number of visits includes a half visit. If the physician provides E&M services in excess of the total number of E&M visits shown for the surgical code, medically necessary E&M services in excess of that number may be separately billed.

(b) The Primary Treating Physician's Progress reports (PR-2 or the equivalent allowed by section 9785) are separately reimbursable even if the change in the patient's condition or treatment warranting a progress report occurs during the surgical global follow-up period.

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).