Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director - Administrative Rules
Article 5.3. Official Medical Fee Schedule

§ 9789.32. Outpatient Hospital Departments and Ambulatory Surgical Centers Fee Schedule - Applicability.

(a) Sections 9789.30 through 9789.39 shall be applicable to the maximum allowable fees for emergency room visits and surgical procedures provided on an outpatient basis rendered on or after July 1, 2004, but before September 1, 2014. Sections 9789.30 through 9789.39 shall be applicable to the maximum allowable fees for emergency room visits, surgical procedures, and Facility Only Services provided on an outpatient basis rendered on or after September 1, 2014, but before December 15, 2016. Sections 9789.30 through 9789.39 shall be applicable to the maximum allowable fees for services provided on an outpatient basis and payable under the Medicare (CMS) HOPPS rendered on or after December 15, 2016. For purposes of this section, emergency room visits and surgical procedures shall be defined by HCPCS codes set forth in section 9789.39(b) by date of service. A supply, drug, device, blood product and biological is considered an integral part of an emergency room visit, or surgical procedure, or, if applicable, Facility Only Service, or if applicable and only if rendered on or after December 15, 2016, Other Service if:

(1)

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(2)

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(b) Sections 9789.30 through 9789.39 apply to any hospital outpatient department as defined in Section 9789.30(p) and any ASC as defined in Section 9789.30(c).

(c) This subsection (c) is inapplicable for dates of services on or after December 15, 2016. Depending on date of service, the maximum allowable fees for services, drugs and supplies furnished by hospitals that do not meet the requirements in (a) for a facility fee payment and are not bundled in the APC payment rate for services in (a) will be determined as follows:

(1)(A) For services rendered before September 1, 2014, the maximum allowable hospital outpatient facility fees for professional medical services which are performed by physicians and other licensed health care providers to hospital outpatients shall be paid according to Section 9789.10 and Section 9789.11.

(B) For Other Services rendered on or after September 1, 2014, but before December 15, 2016, to hospital outpatients, the maximum allowable hospital outpatient facility fees shall be paid according to the OMFS RBRVS.

(i) If the Other Service has a Professional Component/Technical Component under the OMFS RBRVS, the hospital outpatient facility fee shall be the Technical Component amount determined according to the OMFS RBRVS.

(ii) For Other Services, which do not meet the requirement in (i), the hospital outpatient facility fee shall be determined based solely on the non-facility practice expense relative value units applicable under the OMFS RBRVS.

The base facility fee is calculated as follows: Non-Facility Site of Service Practice Expense (PE) Relative Value Unit (RVU) * Statewide Geographic Adjustment Factor (GAF) for PE * RBRVS Conversion Factor (CF) = Base facility fee.

(d) Hospital Outpatient Departments and ASCs should utilize other applicable parts of the OMFS to determine maximum allowable fees for services or goods not covered by the Hospital Outpatient Departments and Ambulatory Surgical Centers fee schedule (Sections 9789.30 through 9789.39).

(1) The fees for any physician and non-physician practitioner professional services shall be determined in accordance with the OMFS RBRVS.

(2) The maximum allowable fees for organ acquisition costs and corneal tissue acquisition costs shall be based on the documented paid cost of procuring the organ or tissue.

(3) The maximum allowable fee for drugs not otherwise covered by a Medicare fee schedule payment for facility services shall be determined pursuant to Labor Code Section 5307.1, or, where applicable, Section 9789.40.

(4) The maximum allowable fee for clinical diagnostic tests shall be determined according to Section 9789.50.

(5) The maximum allowable fee for durable medical equipment, prosthetics and orthotics shall be determined according to Section 9789.60.

(6) The maximum allowable fee for ambulance service shall be determined according to Section 9789.70.

(e) For services rendered before September 1, 2014, only hospitals may charge or collect a facility fee for emergency room visits. Only hospital outpatient departments and ambulatory surgical centers as defined in Section 9789.30(p) and Section 9789.30(c) may charge or collect a facility fee for surgical services provided on an outpatient basis.

For services rendered on or after September 1, 2014, but before December 15, 2016, only hospitals may charge or collect a facility fee for emergency room visits, Facility Only Services, and Other Services. Only hospital outpatient departments and ambulatory surgical centers as defined in Section 9789.30(p) and Section 9789.30(c) may charge or collect a facility fee for surgical services provided on an outpatient basis. Facility fees are not payable to an ambulatory surgical center for any services that are not an integral part of a surgical service.

For services rendered on or after December 15, 2016, only hospitals as defined in Section 9789.30(p) may charge or collect a facility fee for Hospital Outpatient Department Services rendered to a hospital outpatient and payable under the Medicare (CMS) HOPPS. Ambulatory surgical centers as defined in Section 9789.30(c) may charge or collect a facility fee for only surgical services or services that are an integral part of the surgical service provided on an outpatient basis and payable under the Medicare (CMS) HOPPS. Facility fees are not payable to an ambulatory surgical center for any services that are not an integral part of a surgical service. Only ambulatory surgical centers may charge or collect a facility fee for its services.

(f) Hospital outpatient departments and ambulatory surgical centers shall not be reimbursed for procedures on the inpatient only list, referenced in Section 9789.31(a), Addendum E, except that pre-authorized services rendered are payable at the pre-negotiated fee arrangement. The pre-authorization must be provided by an authorized agent of the claims administrator to the provider. The fee agreement and pre-authorization must be memorialized in writing prior to performing the medical services.

(g) Critical access hospitals and hospitals that are excluded from acute PPS are exempt from this fee schedule.

(h) Out of state hospital outpatient departments and ambulatory surgical centers are exempt from this fee schedule.

(i) Hospital outpatient departments and ambulatory surgical centers billing for facility fees and other services under this Section shall be submitted in accordance with the e-billing regulations beginning with Section 9792.5.0 or the standardized paper billing regulations beginning with Section 9792.5.2.

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

HISTORY

1. New section filed 1-2-2004 as an emergency; operative 1-2-2004 (Register 2004, No. 2). A Certificate of Compliance must be transmitted to OAL by 5-3-2004 or emergency language will be repealed by operation of law on the following day.

2. Certificate of Compliance as to 1-2-2004 order, including amendment of section, transmitted to OAL 4-30-2004 and filed 6-15-2004 (Register 2004, No. 25).

3. Amendment of subsections (a), (b), (c)(3), (e) and (h) filed 12-27-2012; operative 1-1-2013 as a file and print only pursuant to Government Code section 11340.9(g) (Register 2012, No. 52).

4. Amendment filed 6-3-2014; operative 9-1-2014 as a file and print only pursuant to Government Code section 11340.9(g) (Register 2014, No. 23).

5. Amendment of subsection (c)(1)(B)(ii) filed 9-23-2014; operative 9-1-2014 as a file and print only pursuant to Government Code section 11340.9(g) (Register 2014, No. 39).

6. Amendment of section heading and section filed 12-15-2016; operative 12-15-2016 as a file and print only pursuant to Government Code section 11340.9(g) (Register 2016, No. 51).

7. Amendment of subsection (a)(1) filed 5-8-2018; operative 3-15-2018 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 2018, No. 19).