A new order from the Administrative Director of California’s Division of Workers’ Compensation (DWC) updates the Physician and Non-Physician Practitioner Services portion of the Official Medical Fee Schedule (OMFS).

The reimbursement changes announced on October 2, 2020, are retroactive to dates of service rendered on or after October 1, 2020.

The changes include updates to the RVU files, NCCI Edits, MUEs, and GPCI locality mapping. Note that the updates to the GPCI file do not affect reimbursements.

In Newsline No.: 2020-86, the DWC announced the order to conform the OMFS for Physician Services / Non-Physician Practitioner Services to Medicare’s October fee schedule release and quarterly updates.

These changes are incorporated into California Code of Regulations (CCR) Section 9789.19 and include:

• The adoption of Medicare’s National Physician Fee Schedule Relative Value File RVU20D October 1, 2020 quarterly update. The RVU20D file is available on the Centers for Medicare and Medicaid Services (CMS) website.
• The adoption of Medicare’s quarterly update to the Practitioner Procedure-to-Procedure (PTP) NCCI Edits. The new NCCI Edits are available on the CMS website.
• The adoption of Medicare’s NCCI Medically Unlikely Edits (MUE) October 1, 2020 quarterly update for Practitioner Services. The Practitioner Services MUE table is available on the CMS website.
• The adoption of Medicare’s ZIP Code to Carrier Locality files October 1, 2020 quarterly update. The GPCI locality mapping files can also be found on the CMS website.

Relative Value File

Effective October 1, 2020, the DWC adopted the CMS Medicare National Physician Fee Schedule Relative Value File RVU20D October 1, 2020 quarterly update.

With the adoption of the new RVU file, 22 new billing codes were added: four G-codes, eight J-codes, seven Q-codes, one T-code, one V-code, and 87426, the latter of which is for coronavirus antigen testing.

The OMFS lists the reimbursement for these codes as By Report (BR). For a procedure code where ‘BR’ is listed as the OMFS Expected reimbursement amount, providers must determine a reasonable amount to charge based on comparable procedure codes. CCR § 9789.12.4 offers guidelines to determine an appropriate reimbursement amount for BR codes.

Geographic Pricing Cost Index (GPCI)

In Newsline No.: 2020-86, the DWC also announced the adoption of the CMS ZIP Code to Carrier Locality files October 1, 2020 quarterly update, for GPCI locality mapping. This file did not contain any changes that would affect reimbursements based on GPCI locality mapping.

As always, DaisyBill clients can rest assured that we incorporate the latest changes into our Fee Schedule Calculator. We’ll keep readers updated on any further OMFS changes.

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