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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


§ 9789.39. Update Table by Date of Service.


(a) Federal Regulations by Date of Service
The Federal Regulations can be accessed at: http://www.cms.gov/HospitalOutpatientPPS/ and the referenced sections are incorporated by reference and will be made available upon request to the Administrative Director.
Services Occurring On
Services Occurring On
Services Occurring On
Services Occurring On
or After 7/15/2005
or After 2/15/2006
or After 3/1/2007
or After 3/1/2008
Title 42, Code of Federal
Regulations, §419.2
Title 42, Code of Federal
Regulations, §419.32
Title 42, Code of Federal
As amended; effective
As amended; effective
As amended; effective
Regulations, §419.43
January 1, 2006
January 1, 2007
January 1, 2008
Title 42, Code of Federal
Amended; effective
Regulations, §419.44
January 1, 2008
Title 42, Code of Federal
Regulations, §419.62
Title 42, Code of Federal
As amended; effective
Regulations, §419.64
January 1, 2005
Title 42, Code of Federal
As amended; effective
Regulations, §419.66
January 1, 2006
Services Occurring On
Services Occurring On
Services Occurring On
Services Occurring On
or After 3/1/2009
or After 4/15/2010
or After 9/15/2011
or After 3/1/2012
Title 42, Code of Federal
Regulations, §419.2
Title 42, Code of Federal
As amended; effective
As amended; effective
Regulations, §419.32
January 1, 2011
January 1, 2012
Title 42, Code of Federal
As amended; effective
As amended; effective
As amended; effective
Regulations, §419.43
January 1, 2009
January 1, 2011
January 1, 2012
Title 42, Code of Federal
Regulations, §419.44
Title 42, Code of Federal
Regulations, §419.62
Title 42, Code of Federal
As amended; effective
Regulations, §419.64
January 1, 2010
Title 42, Code of Federal
As amended; effective
Regulations, §419.66
January 1, 2010
Services Occurring On
Services Occurring On
Services Occurring On or
Services Occurring On or
or After 4/1/2013
or After 12/1/2014
After December 15, 2016
After June 1, 2017
Title 42, Code of Federal
As amended; effective
As amended; effective
As amended; effective
As amended; effective
Regulations, §419.2
January 1, 2013
January 1, 2014
January 1, 2016
January 1, 2016
Title 42, Code of Federal
As amended; effective
As amended; effective
As amended; effective
As amended; effective
Regulations, §419.32
January 1, 2013
January 1, 2014
January 1, 2016
January 1, 2017
Title 42, Code of Federal
As amended; effective
As amended; effective
Regulations, §419.43
January 1, 2012
January 1, 2017
Title 42, Code of Federal
As amended; effective
As amended; effective
Regulations, §419.44
January 1, 2016
January 1, 2017
Title 42, Code of Federal
Effective January 1, 2004
Effective January 1, 2004
Regulations, §419.62
Title 42, Code of Federal
As amended; effective
As amended; effective
Regulations, §419.64
January 1, 2015
January 1, 2015
Title 42, Code of Federal
As amended; effective
As amended; effective
As amended; effective
Regulations, §419.66
January 1, 2014
January 1, 2016
January 1, 2017
Services Occurring On
Services Occurring On
or After March 15, 2018
or After February 15, 2019
Title 42, Code of Federal
As amended; effective
As amended; effective
Regulations, §419.2
January 1, 2016
January 1, 2016
Title 42, Code of Federal
As amended; effective
As amended; effective
Regulations, §419.32
January 1, 2018
January 1, 2019
Title 42, Code of Federal
As amended; effective
As amended; effective
Regulations, §419.43
January 1, 2017
January 1, 2017
Title 42, Code of Federal
As amended; effective
As amended; effective
Regulations, §419.44
January 1, 2017
January 1, 2017
Title 42, Code of Federal
Effective January 1, 2004
Effective January 1, 2004
Regulations, §419.62
Title 42, Code of Federal
As amended; effective
As amended; effective
Regulations, §419.64
January 1, 2015
January 1, 2015
Title 42, Code of Federal
As amended; effective
As amended; effective
Regulations, §419.66
January 1, 2017
January 1, 2017
Title 42, Code of Federal
Effective January 1, 2018
Effective January 1, 2018
Regulations, §419.71
(b) Update factors and Federal Register Notices by Date of Service
The Federal Register Notices can be accessed at: http://www.cms.gov/HospitalOutpatientPPS/ and the referenced sections are incorporated by reference and will be made available upon request to the Administrative Director.
Image 1 within § 9789.39. Update Table by Date of Service.
Image 2 within § 9789.39. Update Table by Date of Service.
Image 3 within § 9789.39. Update Table by Date of Service.
Image 4 within § 9789.39. Update Table by Date of Service.
Image 5 within § 9789.39. Update Table by Date of Service.
Image 6 within § 9789.39. Update Table by Date of Service.
Image 7 within § 9789.39. Update Table by Date of Service.
Image 8 within § 9789.39. Update Table by Date of Service.
Image 9 within § 9789.39. Update Table by Date of Service.
Image 10 within § 9789.39. Update Table by Date of Service.
Image 11 within § 9789.39. Update Table by Date of Service.
Image 12 within § 9789.39. Update Table by Date of Service.
Image 13 within § 9789.39. Update Table by Date of Service.
Image 14 within § 9789.39. Update Table by Date of Service.
Image 15 within § 9789.39. Update Table by Date of Service.
Image 16 within § 9789.39. Update Table by Date of Service.
Image 17 within § 9789.39. Update Table by Date of Service.
Image 18 within § 9789.39. Update Table by Date of Service.
Image 19 within § 9789.39. Update Table by Date of Service.
Services Occurring On or After February 15, 2019 and Mid-year Updates
Applicable FR Notices
(A) November 21, 2018 (CMS-1695-FC; 83 FR 58818)
(B) December 28, 2018 (CMS-1695-CN2; 83 FR 67083)
(C) August 17, 2018 (CMS-1694-F; 83 FR 41144)
(D) October 3, 2018 (CMS-1694-CN2; 83 FR 49836)
Ambulatory Surgical Centers
For services occurring on or after February 15, 2019, Column A, of Addendum AA, entitled, “HCPCS Code”
Payment System Addenda
and Column A, of Addendum EE, entitled, “HCPCS Code” located in “January 2019 ASC Approved HCPCS Code
and Payment Rates - Updated 01/29/2019” (jan_2019_asc_addenda_1_28_19.xlsx)
For services occurring on or after April 1, 2019, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A,
of Addendum EE, entitled, “HCPCS Code” located in “April 2019 ASC Approved HCPCS Code and Payment Rates -
Updated 3/28/2019” (Apr_2019_ASC_Addenda_3_27_2019)
For services occurring on or after July 1, 2019, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of
Addendum EE, entitled, “HCPCS Code” located in “July 2019 ASC Approved HCPCS Code and Payment Rates -
Updated 06/27/2019” (July_2019_ASC_Addenda.06262019.xlsx)
For services occurring on or after October 1, 2019, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A,
of Addendum EE, entitled, “HCPCS Code” located in “October 2019 ASC Approved HCPCS Code and Payment Rates
CORRECTIONS - Updated 10/15/2019” (October_2019_ASC_Addenda.CORRECTED.10152019.xlsx)
Note:
Access the files on CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ ASCPayment/index.html
APC Payment Rate
For services occurring on or after February 15, 2019, Addendum B, dated January 2019 (january_2019_opps_web_
addendum_b.12312018.xlsx)
For services occurring on or after April 1, 2019, Addendum B, dated April 2019 (2019_April_Web_
Addendum_B.03222019.xlsx)
For services occurring on or after July 1, 2019, Addendum B, dated July 2019 (July_2019_Web_Addendum_B.06212019.xlsx)
For services occurring on or after October 1, 2019, Addendum B - Correction, dated October 2019 (2019_October_Web_
Addendum_B.CORRECTED.09292019.xlsx)
APC Relative Weight
For services occurring on or after February 15, 2019, Addendum B, dated January 2019 (january_2019_opps_web_
addendum_b.12312018.xlsx)
For services occurring on or after April 1, 2019, Addendum B, dated April 2019 (2019_April_Web_
Addendum_B.03222019.xlsx)
For services occurring on or after July 1, 2019, Addendum B, dated July 2019 (July_2019_Web_Addendum_B.06212019.xlsx)
For services occurring on or after October 1, 2019, Addendum B - Correction, dated October 2019 (2019_October_Web_
Addendum_B.CORRECTED.09292019.xlsx)
Composite APCs (codes
For services occurring on or after February 15, 2019, payment rules are:
assigned status indicator “Q1,”
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
“Q2,” “Q3,” or “Q4”) payment
• CMS 2019 OPPS Addendum D1
rules
• CMS 2019 OPPS Addendum M
• IOCE Quarterly Data Files V20.0 ¿ZIP, 52MBº, IntegOCEspecsV20.0.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after April 1, 2019, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2019 OPPS Addendum D1
• CMS 2019 OPPS Addendum M
• IOCE Quarterly Data Files V20.1 ¿ZIP, 50MBº, IntegOCEspecsV20.1.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after July 1, 2019, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2019 OPPS Addendum D1
• CMS 2019 OPPS Addendum M
• IOCE Quarterly Data Files V20.2 ¿ZIP, 50MBº, IntegOCEspecsV20.2.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after October 1, 2019, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2019 OPPS Addendum D1
• CMS 2019 OPPS Addendum M
• IOCE Quarterly Data Files V20.3 ¿ZIP, 50 MBº IntegOCEspecsV20.3.pdf, sections 4.4.1, 4.4.3, 4.4.5, and 4.5
Note:
A copy of the IOCE is posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm#6
Access documents on the CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HospitalOutpatientPPS/index.html?redirect= /HospitalOutpatientPPS/ and CMS Claims Processing Manual
at: https://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/Internet-Only-Manuals-IOMs-
Items/CMS018912.html
Comprehensive APCs (codes
For services occurring on or after February 15, 2019, payment rules are:
assigned status indicator
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.4, 290.5.2, and 290.5.3
“J1” or “J2”) payment rules
• CMS 2019 OPPS Addendum D1
• CMS 2019 OPPS Addendum J
• IOCE Quarterly Data Files V20.0 ¿ZIP, 52MBº, IntegOCEspecsV20.0.pdf, sections 5.6.1, 5.6.1.1, 5.6.2, 5.6.3,
5.6.4, 5.6.4.1, and 5.6.4.2
For services occurring on or after April 1, 2019, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2019 OPPS Addendum D1
• CMS 2019 OPPS Addendum M
• IOCE Quarterly Data Files V20.1 ¿ZIP, 50MBº, IntegOCEspecsV20.1.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after July 1, 2019, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2019 OPPS Addendum D1
• CMS 2019 OPPS Addendum M
• IOCE Quarterly Data Files V20.2 ¿ZIP, 50MBº, IntegOCEspecsV20.2.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after October 1, 2019, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2019 OPPS Addendum D1
• CMS 2019 OPPS Addendum M
• IOCE Quarterly Data Files V20.3 ¿ZIP, 50MBº, IntegOCEspecsV20.3.pdf, sections 4.4.1, 4.4.3, 4.4.5, and 4.5
Note:
A copy of the IOCE is posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm
Access documents on the CMS website at: https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/HospitalOut
And CMS Claims Processing Manual at: https://www.cms.gov/Regulatiions-and-Guidance/Guidance/ Manuals/Internet-Only-
Manuals-IOMs-Items/CMS018912.html?DLPage= =1&DLEntries=10&DLSort=0&DLSortDir=ascending
Emergency Department
99281-99285, 99291, 99292, G0380-G0384, G0390
HCPCS Codes
Facility Only Services
Not applicable for services rendered on or after December 15, 2016
Film X-ray services and
Use modifier “FX” to report X-rays taken using film, which requires a 20 percent payment reduction for such service. Use modifier
X-rays taken using computed
“FY” to report X-rays taken using computed radiography technology/cassette-based imaging which requires a 7 percent payment
radiography technology/cassette
reduction for such service. Apply payment rules set forth in:
-based imaging payment
• December 14, 2017 (CMS-1678-FC; 82 FR 592216, Republished section X.E., pages 59391 through 59393)
reductions
• Medicare Claims Processing Manual, Chapter 4, section 20.6.14 (effective 01/01/2018) and section 20.6.15 (effective 1/01/2018)
• CFR section 419.71
• CMS' April 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS) CR 10515 Revised March 22, 2018,
Transmittal R4005CP, section 6
Access the Medicare Claims Processing Manual on the CMS website at: https://www.cms. gov/Regulations-and-Guidance/Guidance/ Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html
HOPPS Addenda
For services occurring on or after February 15, 2019 addenda:
• A (January 2019; january_2019_opps_web_addendum_a.12312018.xlsx)
• B (January 2019; january_2019_opps_web_addendum_b.12312018.xlsx)
• D1 (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum D1.11012018.xlsx)
• D2 (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum D2.11012018.xlsm)
• E (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum E.11012018.xlsx)
• J (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum J.11012018.xls)
• L (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum L.11012018.xlsx)
• M (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum M.11012018.xlsx)
• P (2019 CN2 OPPS Addenda; 2019 CN2 Addendum P.12212018.xlsx)
For services occurring on or after April 1, 2019 addenda:
• A (April 2019; 2019_April_Web_Addendum_A.03222019.xlsx)
• B (April 2019; 2019_April_Web_Addendum_B.03222019.xlsx)
• D1 (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum D1.11012018.xlsx)
• D2 (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum D2.11012018.xlsm)
• E (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum E.11012018.xlsx)
• J (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum J.11012018.xls)
• L (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum L.11012018.xlsx)
• M (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum M.11012018.xlsx)
• P (2019 CN2 OPPS Addenda; 2019 CN2 Addendum P.12212018.xlsx)
For services occurring on or after July 1, 2019 addenda:
• A (July 2019; July_2019_Web_Addendum_A.06212019.xlsx)
• B (July 2019; July_2019_Web_Addendum_B.06212019.xlsx)
• D1 (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum D1.11012018.xlsx)
• D2 (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum D2.11012018.xlsm)
• E (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum E.11012018.xlsx)
• J (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum J.11012018.xls)
• L (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum L.11012018.xlsx)
• M (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum M.11012018.xlsx)
• P (2019 CN2 OPPS Addenda; 2019 CN2 Addendum P.12212018.xlsx)
For services occurring on or after October 1, 2019 addenda:
• A (October 2019; 2019_October_Web_Addendum_A.CORRECTED.09292019.xlsx)
• B (October 2019; 2019_October_Web_Addendum_B.CORRECTED.09292019.xlsx)
• D1 (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum D1.11012018.xlsx)
• D2 (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum D2.11012018.xlsm)
• E (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum E.11012018.xlsx)
• J (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum J.11012018.xls)
• L (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum L.11012018.xlsx)
• M (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum M.11012018.xlsx)
• P (2019 CN2 OPPS Addenda; 2019 CN2 Addendum P.12212018.xlsx)
Note:
Access the files on the CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/
HospitalOutpatientPPS/index.html
IPPS Tables
FY 2019 Tables 2, 3 and 4 (Wage Index Tables) (Final Rule and Correction Notice) [ZIP,
1MB] found at: https://www.cms.gov/Medicare/Medicare-Fee-for- Service-Payment/AcutelnpatientPPS/FY2019-IPPS-
Final-Rule-Home-Page-Items/FY2019-IPPS-Final-Rule-Tables .html?DLPage=1&DLEntries=10&DLSort=0&DLSort
Dir=ascending
Labor-related Share
60% (A) beginning at page 58863
Market Basket Inflation Factor
2.9% (A) page 58822
Medicare Physician Fee
Schedule Relative Value File
Not applicable for services rendered on or after December 15, 2016
Surgical Procedure HCPCS
For services rendered on or after February 15, 2019, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center
Payment System (ASC) “Jan 2019 ASC AA,” Column A, of CMS' ASC “Jan 2019 ASC EE, and CPT codes 21811-21813,
33289, and 36415, but, excluding HCPCS codes listed on CMS' 2019 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “January 2019 ASC Approved HCPCS Code and Payment Rates - Updated-
01/29/2019” (jan_2019_asc_addenda_1_28_19.xlsx) at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ASCPayment/11_Addenda_Updates.html
2019 HOPPS Addendum E (CY2019 NFRM Addendum E.11012018.xlsx) is found at: https://www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/ Hospital-Outpatient-Regulations-and-Notices-
Items/CMS-1695-FC.html?DLPage= 1&DLEntries=10&DLSort=2&DLSortDir=descending
For services rendered on or after April 1, 2019, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center
Payment System (ASC) “Apr 2019 ASC AA,” Column A, of CMS' ASC “Apr 2019 ASC EE,” and CPT codes 21811-21813,
33289, and 36415, but, excluding HCPCS codes listed on CMS' 2019 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “April 2019 ASC Approved HCPCS Code and Payment Rates - Updated 3/28/19”
(Apr_2019_ASC_Addenda_3_27_2019) at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/
ASCPayment/11_Addenda_Updates.html
2019 HOPPS Addendum E (CY2019 NFRM Addendum E.11012018.xlsx) is found at: https://www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/ Hospital-Outpatient-Regulations-and-Notices-Items/
CMS-1695-FC.html?DLPage=1& DLEntries=10&DLSort=2&DLSortDir=descending
For services rendered on or after July 1, 2019, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment
System (ASC) “Jul 2019 ASC AA,” Column A, of CMS' ASC “Jul 2019 ASC EE,” and CPT codes 21811-21813, 33289, and
36415, but, excluding HCPCS codes listed on CMS' 2019 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “July 2019 ASC Approved HCPCS Code and Payment Rates - Updated 06/27/2019”
(July_2019_ASC_Addenda.06262019.xlsx) at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/
ASCPayment/11_Addenda_Updates.html
2019 HOPPS Addendum E (CY2019 NFRM Addendum E.11012018.xlsx) is found at: https://www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/ HospitalOutpatientPPS/ Hospital-Outpatient-Regulations-and-Notices-Items/
CMS-1695-FC.html?DLPage=1& DLEntries=10&DLSort=2&DLSortDir=descending
For services rendered on or after October 1, 2019, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center
Payment System (ASC) “Oct 2019 ASC AA,” Column A, of CMS' ASC “Oct 2019 ASC EE,” and CPT codes 21811-21813, 3289,
and 36415, but, excluding HCPCS codes listed on CMS' 2019 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “October 2019 ASC Approved HCPCS Code and Payment Rates
CORRECTIONS - Updated 10/15/2019” (October_2019_ASC_Addenda.CORRECTED.10152019.xlsx) at:
https://www.cms.gov/ Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/index.html
2019 HOPPS Addendum E (CY2019 NFRM Addendum E.11012018.xlsx) is found at: https://www.cms. gov/Medicare/
Medicare-Fee-for-Service-Payment/ HospitalOutpatientPPS/ Hospital-Outpatient-Regulations-and-Notices-Items/
CMS-1695-FC.html?DLPage=1& DLEntries=10&DLSort=2&DLSortDir=descending
Conversion Factor
$82.945 (2018 unadjusted conversion factor of $80.607 x estimated inflation factor of 1.029)
adjusted for inflation factor
Wage Index
Referenced in (A) beginning at page 58876; wage index values are specified in Table 2 (C) and (D) found on the CMS website
at https://www.cms.gov/Medicare/Medicare-Fee-for- Service-Payment/AcutelnpatientPPS/FY2019-IPPS-Final-Rule-
Home-Page-Items/FY2019-IPPS-Final-Rule-Tables.html?DLPage =1&DLEntries=10&DLSort=0&DLSortDir=ascending
Services Occurring On or After March 1, 2020 and Mid-year Updates
Applicable FR Notices
(A) November 12, 2019 (CMS-1717-FC; 84 FR 61142)
(B) January 3, 2020 (CMS-1717-CN; 85 FR 224)
(C) August 16, 2019 (CMS-1716-F; 84 FR 42044)
(D) October 8, 2019 (CMS-1716-CN2; 84 FR 53603)
Ambulatory Surgical
Centers Payment System
Addenda
For services occurring on or after March 1, 2020, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of
Addendum EE, entitled, “HCPCS Code” located in “CY 2020 CN ASC Addenda.12122019” (CY 2020
CN ASC Addenda.12122019.xlsx)
Note:
Access the files on CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/
ASCPayment/index.html
APC Payment Rate
For services occurring on or after March 1, 2020, Addendum B, dated December 2019 (2020 CN Addendum B.12202019.xlsx)
APC Relative Weight
For services occurring on or after March 1, 2020, Addendum B, dated December 2019 (2020 CN Addendum B.12202019.xlsx)
Composite APCs (codes
For services occurring on or after March 1, 2020, payment rules are:
assigned status indicator
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
“Q1,” “Q2,” “Q3,” or “Q4”)
• CMS 2020 OPPS Addendum D1
payment rules
• CMS 2020 OPPS Addendum M
• IOCE Quarterly Data Files V21.0 ¿ZIP, 1.17MBº, IntegOCEspecsV21.0.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
Note:
A copy of the IOCE is posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm
Access documents on the CMS website at: https://www.cms. gov/Medicare/Medicare-Fee-for-Service-Payment/
HospitalOutpatientPPS/index and CMS Claims Processing Manual at: https://www.cms.gov/Regulations-and-Guidance/
Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html
Comprehensive APCs (codes
For services occurring on or after March 1, 2020, payment rules are:
assigned status indicator “J1”
• Medicare Claims Processing Manual Chapter 4, sections 10.2.3, 10.4, 290.5.2, and 290.5.3
or “J2”) payment rules
• CMS 2020 OPPS Addendum D1
• CMS 2020 OPPS Addendum J
• IOCE Quarterly Data Files V21.0 ¿ZIP, 1.17MBº, IntegOCEspecsV21.0.pdf, sections 5.6.1, 5.6.1.1, 5.6.2, 5.6.3, 5.6.4,
5.6.4.1, and 5.6.4.2
Note:
A copy of the IOCE is posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm#6
Access documents on the CMS website at: https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/Hospital
OutpatientPPS/index and CMS Claims Processing Manual at: https://www.cms.gov/Regulations-and-Guidance/Guidance/
Manuals/Internet-Only-Manuals -IOMs-Items/CMS018912.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=
ascending
Emergency Department
99281-99285, 99291, 99292, G0380-G0384, G0390
HCPCS Codes
Facility Only Services
Not applicable for services rendered on or after December 15, 2016
Film X-ray services and
Use modifier “FX” to report X-rays taken using film, which requires a 20 percent payment reduction for such service. Use modifier
X-rays taken using computed
“FY” to report X-rays taken using computed radiography technology/cassette-based imaging which requires a 7 percent
radiography technology/cassette-
payment reduction for such service. Apply payment rules set forth in:
based imaging payment
• December 14, 2017 (CMS-1678-FC; 82 FR 59216, Republished, section X.E., pages 59391 through 59393)
reductions
• Medicare Claims Processing Manual, Chapter 4, section 20.6.14 (effective 01/01/2018) and section 20.6.15 (effective 01/01/2018)
• CFR section 419.71
• CMS' April 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS) CR 10515 Revised March 22, 2018, Transmittal R4005CP, section 6
Access the Medicare Claims Processing Manual on the CMS website at: https://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html
HOPPS Addenda
For services occurring on or after March 1, 2020 addenda:
• A (CY2020 CN Addendum A; CY2020 Addendum A. 12202019.xlsx)
• B (CY2020 CN Addendum B; CY2020 Addendum B. 12202019.xlsx)
• D1 (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum D1.11012019.xlsx)
• D2 (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum D2.11012019.xlsm)
• E (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum E.11012019.xlsx)
• J (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum J.11012019.xls)
• L (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum L.11012019.xlsx)
• M (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum M.11012019.xlsx)
• P (2020 CN Addendum P; CY2020 CN Addendum P.12202019.xlsx)
Note:
Access the files on the CMS website at: https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/Hospital
OutpatientPPS/index.html
IPPS Tables
FY 2020 Tables 2, 3 and 4 (Wage Index Tables) (Final Rule and Correction Notice) [ZIP, 1MB] found at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/AcutelnpatientPPS/FY2020-IPPS-Final-Rule-Home-Page-Items/
FY2020-IPPS-Final-Rule-Tables
Labor-related Share
60% (A) beginning at page 61184
Market Basket Inflation Factor
3% (A) page 61145
Medicare Physician Fee
Not applicable for services rendered on or after December 15, 2016
Schedule Relative Value File
Surgical Procedure HCPCS
For services rendered on or after March 1, 2020, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment
System (ASC) “Jan 2020 ASC AA,” Column A, of CMS' ASC “Jan 2020 ASC EE, and CPT codes 21811-21813, 33289, and
36415, but, excluding HCPCS codes listed on CMS' 2020 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “January 2020 ASC Approved HCPCS Code and Payment Rates - Updated
01/01/2020” (cy2020_january_asc_addenda.01022020.xlsx) at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service
-Payment/ASCPayment/11_Addenda_Updates
2020 HOPPS Addendum E (2020 NFRM Addendum E.11012019.xlsx) is found at: https://www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/ HospitalOutpatientPPS/ Hospital-Outpatient-Regulations-and-Notices-Items/
CMS-1695-FC.html?DLPage=1& DLEntries=10&DLSort=2&DLSortDir=descending
Conversion Factor adjusted
$ 85.433 (2019 unadjusted conversion factor of $82.945 x estimated inflation factor of 1.03)
for inflation factor
Wage Index
Referenced in (A) beginning at page 61184; wage index values are specified in Table 2 (C) and (D) found on the CMS website at
https://www.cms.gov/Medicare/Medicare-Fee-for- Service-Payment/AcutelnpatientPPS/FY2020-IPPS-Final-
Rule-Home-Page-Items/FY2020-IPPS-Final-Rule-Tables
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 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).
2. Amendment filed 3-29-2013; operative 4-1-2013 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 2013, No. 13).
3. Amendment of section heading and section 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).
4. Amendment filed 12-4-2014; operative 12-1-2014 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 2014, No. 49).
5. Amendment 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).
6. Editorial correction of subsection (b) (Register 2017, No. 18).
7. Amendment filed 6-20-2017; operative 6-1-2017 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 2017, No. 25).
8. Amendment 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).
9. Editorial correction (Register 2019, No. 5).
10. Amendment filed 2-14-2019; operative 2-15-2019 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 2019, No. 7).
11. Editorial correction (Register 2019, No. 33).
12. Amendment of subsection (b) filed 3-19-2020; operative 3-1-2020 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 2020, No. 12).


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