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2019 CA Workers’ Comp Evaluation & Management Cheat Sheet

February 1, 2019 by James Carey

The 2019 changes to California’s reimbursements got your head spinning? Here’s a handy reimbursement cheat sheet for the most frequently used Evaluation & Management codes.

Use this to start grappling with Medicare Geographic Practice Cost Indices (GPCIs), newly implemented for the workers’ comp Official Medical Fee Schedule (OMFS) as of 1/1/2019.

The tables below compare the 2019 reimbursement to the previous 2018 reimbursement for seven of the most popular Evaluation and Management codes. Depending on the location where services are provided to the injured worker, the adoption of Medicare GPCIs results in a reduced 2019 reimbursement for some providers while increasing the reimbursement for other providers.

As a reminder, with the adoption of location-based reimbursement, effective for all dates of service on or after 1/1/2019, California no longer reimburses providers using a single state-wide geographic adjustment factor (GAF). Instead, the reimbursement calculation now uses three location-based GPCIs (PW, PE, MP) assigned by Medicare to the place of service.

We organized the comparison table from the lowest to highest reimbursement areas. This organization gives you an idea as to where you stand relative to the rest of the state.

As a bonus, we put the 2018 baseline rates in the middle to illustrate the cutoff between areas with reduced rates and those with increased rates. For localities above the 2018 reimbursement line for each code, 2019 reimbursements are less than 2018 reimbursements. For localities below the 2018 reimbursement line for each code, then 2019 reimbursements are more than 2018 reimbursements.

These OMFS reimbursements are effective for dates of service on or after January 1, 2019, and are representative of all the 32 distinct geographic regions delineated by the new GPCI methodology.

2019 Reimbursements for Office/Outpatient Visit - New

Place of Service County

2019 vs 2018 OMFS Reimbursement

99203 Non Facility

99204 Non Facility

99205 Non Facility

CHICO

OMFS Reduction

$143.39

$217.05

$272.41

FRESNO

OMFS Reduction

$143.39

$217.05

$272.41

MADERA

OMFS Reduction

$143.39

$217.05

$272.41

MERCED

OMFS Reduction

$143.39

$217.05

$272.41

MODESTO

OMFS Reduction

$143.39

$217.05

$272.41

REDDING

OMFS Reduction

$143.39

$217.05

$272.41

STOCKTON-LODI

OMFS Reduction

$143.39

$217.05

$272.41

VISALIA-PORTERVILLE

OMFS Reduction

$143.39

$217.05

$272.41

YUBA CITY

OMFS Reduction

$143.39

$217.05

$272.41

REST OF STATE*

OMFS Reduction

$143.39

$217.05

$272.41

EL CENTRO

OMFS Reduction

$143.44

$217.13

$272.51

HANFORD-CORCORAN

OMFS Reduction

$143.45

$217.16

$272.55

BAKERSFIELD

OMFS Reduction

$143.75

$217.59

$273.10

SAN LUIS OBISPO-PASO ROBLES-ARROYO GRANDE

OMFS Reduction

$144.07

$217.96

$273.50

RIVERSIDE-SAN BERNARDINO-ONTARIO

OMFS Reduction

$144.68

$219.00

$274.92

SACRAMENTO--ROSEVILLE--ARDEN-ARCADE

OMFS Reduction

$145.07

$219.47

$275.39

SALINAS

OMFS Reduction

$145.62

$220.18

$276.23

SAN DIEGO-CARLSBAD

OMFS Reduction

$146.50

$221.29

$277.53

SANTA ROSA

OMFS Reduction

$147.47

$222.60

$279.10

SANTA MARIA-SANTA BARBARA

OMFS Reduction

$147.72

$223.13

$279.83

2018 REIMBURSEMENT

$149.04

$225.94

$283.28

SANTA CRUZ-WATSONVILLE

OMFS Increase

$149.98

$226.10

$283.36

OXNARD-THOUSAND OAKS-VENTURA

OMFS Increase

$151.33

$227.87

$285.50

LOS ANGELES-LONG BEACH-ANAHEIM (ORANGE CNTY)

OMFS Increase

$152.96

$230.62

$289.06

LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES CNTY)

OMFS Increase

$152.96

$230.62

$289.06

SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO CNTY)

OMFS Increase

$155.04

$233.39

$292.34

NAPA

OMFS Increase

$157.43

$236.55

$296.07

VALLEJO-FAIRFIELD

OMFS Increase

$157.43

$236.55

$296.07

SAN FRANCISCO-OAKLAND-HAYWARD (MARIN CNTY)

OMFS Increase

$160.48

$240.86

$301.34

OAKLAND/BERKLEY

OMFS Increase

$163.21

$244.72

$306.05

SAN FRANCISCO

OMFS Increase

$163.21

$244.72

$306.05

SAN MATEO

OMFS Increase

$163.21

$244.72

$306.05

SANTA CLARA

OMFS Increase

$165.50

$247.94

$309.97


2019 Reimbursements for Office/Outpatient Visit - Established

Place of Service County

2019 vs 2018 OMFS Reimbursement

99212 Non Facility

99213 Non Facility

99214 Non Facility

99215 Non Facility

CHICO

OMFS Reduction

$60.41

$98.87

$144.62

$193.15

FRESNO

OMFS Reduction

$60.41

$98.87

$144.62

$193.15

MADERA

OMFS Reduction

$60.41

$98.87

$144.62

$193.15

MERCED

OMFS Reduction

$60.41

$98.87

$144.62

$193.15

MODESTO

OMFS Reduction

$60.41

$98.87

$144.62

$193.15

REDDING

OMFS Reduction

$60.41

$98.87

$144.62

$193.15

STOCKTON-LODI

OMFS Reduction

$60.41

$98.87

$144.62

$193.15

VISALIA-PORTERVILLE

OMFS Reduction

$60.41

$98.87

$144.62

$193.15

YUBA CITY

OMFS Reduction

$60.41

$98.87

$144.62

$193.15

REST OF STATE*

OMFS Reduction

$60.41

$98.87

$144.62

$193.15

EL CENTRO

OMFS Reduction

$60.42

$98.90

$144.66

$193.21

HANFORD-CORCORAN

OMFS Reduction

$60.43

$98.92

$144.69

$193.25

BAKERSFIELD

OMFS Reduction

$60.51

$99.05

$144.88

$193.54

SAN LUIS OBISPO-PASO ROBLES-ARROYO GRANDE

OMFS Reduction

$60.75

$99.35

$145.29

$193.99

RIVERSIDE-SAN BERNARDINO-ONTARIO

OMFS Reduction

$60.78

$99.53

$145.57

$194.56

SACRAMENTO--ROSEVILLE--ARDEN-ARCADE

OMFS Reduction

$61.18

$100.05

$146.31

$195.35

SALINAS

OMFS Reduction

$61.47

$100.44

$146.84

$196.01

2018 REIMBURSEMENT

$61.67

SAN DIEGO-CARLSBAD

$61.93

$101.05

$147.68

$197.04

2018 REIMBURSEMENT

$101.39

SANTA ROSA

$62.42

$101.74

$148.64

$198.26

SANTA MARIA-SANTA BARBARA

$62.46

$101.91

$148.93

$198.70

2018 REIMBURSEMENT

$149.32

$200.52

SANTA CRUZ-WATSONVILLE

OMFS Increase

$63.62

$103.50

$151.13

$201.46

OXNARD-THOUSAND OAKS-VENTURA

OMFS Increase

$64.21

$104.32

$152.23

$202.91

LOS ANGELES-LONG BEACH-ANAHEIM (ORANGE CNTY)

OMFS Increase

$64.76

$105.41

$153.91

$205.26

LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES CNTY)

OMFS Increase

$64.76

$105.41

$153.91

$205.26

SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO CNTY)

OMFS Increase

$65.93

$107.03

$156.19

$208.06

NAPA

OMFS Increase

$67.25

$108.86

$158.74

$211.18

VALLEJO-FAIRFIELD

OMFS Increase

$67.25

$108.86

$158.74

$211.18

SAN FRANCISCO-OAKLAND-HAYWARD (MARIN CNTY)

OMFS Increase

$68.67

$110.99

$161.77

$215.10

OAKLAND/BERKLEY

OMFS Increase

$69.99

$112.95

$164.56

$218.68

SAN FRANCISCO

OMFS Increase

$69.99

$112.95

$164.56

$218.68

SAN MATEO

OMFS Increase

$69.99

$112.95

$164.56

$218.68

SANTA CLARA

OMFS Increase

$71.10

$114.59

$166.90

$221.67

Want to stay up-to-date with OMFS changes effortlessly? Sign up for DaisyBill’s Wizard, which includes our amazing Calculator. Enjoy a three day free trial of instant fee schedule reimbursements for seven fee schedules (yes, we already have GPCIs figured into our calculations).

OMFS CALCULATOR
FREE TRIAL!
 

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